Provider Demographics
NPI:1306411376
Name:DEFUNKIFY COUNSELING & CONSULTATION, LLC
Entity Type:Organization
Organization Name:DEFUNKIFY COUNSELING & CONSULTATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONCH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAKOVAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-971-1053
Mailing Address - Street 1:3484 N BRYCE CANYON PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3484 N BRYCE CANYON PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6061
Practice Address - Country:US
Practice Address - Phone:208-971-1054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health