Provider Demographics
NPI:1043629207
Name:CONRAD, JACINDA (MA, CADC)
Entity Type:Individual
Prefix:
First Name:JACINDA
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1071
Mailing Address - Country:US
Mailing Address - Phone:208-336-9076
Mailing Address - Fax:
Practice Address - Street 1:5420 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1071
Practice Address - Country:US
Practice Address - Phone:208-336-9076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10212101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)