Provider Demographics
NPI:1083860415
Name:IDAHO STATE UNIVERSITY - MERIDIAN
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY - MERIDIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE CHAIR
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC SLP
Authorized Official - Phone:208-373-1728
Mailing Address - Street 1:1311 E CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7991
Mailing Address - Country:US
Mailing Address - Phone:208-373-1728
Mailing Address - Fax:208-373-1811
Practice Address - Street 1:1311 E CENTRAL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7991
Practice Address - Country:US
Practice Address - Phone:208-373-1728
Practice Address - Fax:208-373-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty