Provider Demographics
NPI:1538383054
Name:PINGREE, JONATHON JAMES (LCSW)
Entity type:Individual
Prefix:MR
First Name:JONATHON
Middle Name:JAMES
Last Name:PINGREE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 W DIVIDE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3426
Mailing Address - Country:US
Mailing Address - Phone:208-376-0191
Mailing Address - Fax:208-658-6299
Practice Address - Street 1:10740 W FAIRVIEW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7926
Practice Address - Country:US
Practice Address - Phone:208-376-0191
Practice Address - Fax:208-658-6299
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-259791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical