Provider Demographics
NPI:1063674786
Name:SULLIVAN, JESSIE ELAINE (LCPC,LMFT)
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:ELAINE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCPC,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 COLTS GLEN LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8353
Mailing Address - Country:US
Mailing Address - Phone:208-524-2411
Mailing Address - Fax:
Practice Address - Street 1:660 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5299
Practice Address - Country:US
Practice Address - Phone:208-523-1558
Practice Address - Fax:208-529-4788
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-119101YM0800X
IDLMFT-2963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist