Provider Demographics
NPI:1093205684
Name:MCCRILLIS, JENNIFER LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:MCCRILLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1183
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-1183
Mailing Address - Country:US
Mailing Address - Phone:530-321-3051
Mailing Address - Fax:
Practice Address - Street 1:1300 ARROWHEAD PLAZA
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:530-321-3051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID36-717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health