Provider Demographics
NPI:1154060390
Name:ISOM, JESSICA ASHLEY
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ASHLEY
Last Name:ISOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4238
Mailing Address - Country:US
Mailing Address - Phone:208-351-0486
Mailing Address - Fax:
Practice Address - Street 1:230 W 15TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4238
Practice Address - Country:US
Practice Address - Phone:208-351-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDXA174526J106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician