Provider Demographics
NPI:1770637316
Name:COUNTIES OF JEROME LINCOLN
Entity type:Organization
Organization Name:COUNTIES OF JEROME LINCOLN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-2392
Mailing Address - Street 1:125 4TH AVE WEST
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338
Mailing Address - Country:US
Mailing Address - Phone:208-324-2392
Mailing Address - Fax:208-324-7609
Practice Address - Street 1:830 10TH AVE EAST
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338
Practice Address - Country:US
Practice Address - Phone:208-324-3361
Practice Address - Fax:208-324-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805094400Medicaid