Provider Demographics
NPI:1730953605
Name:EDMUNDS, JESSICA ELLEN (CRC, LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELLEN
Last Name:EDMUNDS
Suffix:
Gender:F
Credentials:CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 S OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3447
Mailing Address - Country:US
Mailing Address - Phone:208-964-0202
Mailing Address - Fax:
Practice Address - Street 1:7192 W POTOMAC DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9147
Practice Address - Country:US
Practice Address - Phone:208-489-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7034101YM0800X, 101Y00000X
ID340617225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor