Provider Demographics
NPI:1013223445
Name:NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:NORTHWEST NEUROBEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LA JEUNESSE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CMPE
Authorized Official - Phone:208-283-9121
Mailing Address - Street 1:2076 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6707
Mailing Address - Country:US
Mailing Address - Phone:208-955-7333
Mailing Address - Fax:
Practice Address - Street 1:2076 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6707
Practice Address - Country:US
Practice Address - Phone:208-955-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202425103TC0700X
IDPSY-202505103TC0700X
IDLMSW-29787104100000X
IDLMSW-30636104100000X
IDLCSW-284311041C0700X
IDSLP-1687235Z00000X, 235Z00000X
IDPSY-202444103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1369079OtherMEDICARE PTAN