Provider Demographics
NPI:1083017578
Name:MILES, JENNIFER MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:MILES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:PARKHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JENNIFER LARSEN
Mailing Address - Street 1:1368 EL RANCHO
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2803
Mailing Address - Country:US
Mailing Address - Phone:208-339-6565
Mailing Address - Fax:
Practice Address - Street 1:1368 EL RANCHO BLVD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2808
Practice Address - Country:US
Practice Address - Phone:208-339-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-353411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty