Provider Demographics
NPI:1538909098
Name:PROVANT, JADEN CHARLOTTE-MARGARET (LMSW)
Entity type:Individual
Prefix:
First Name:JADEN
Middle Name:CHARLOTTE-MARGARET
Last Name:PROVANT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5964
Mailing Address - Country:US
Mailing Address - Phone:208-957-3950
Mailing Address - Fax:
Practice Address - Street 1:2995 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5964
Practice Address - Country:US
Practice Address - Phone:208-957-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID452211041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool