Provider Demographics
NPI:1326756347
Name:REVIVE MENTAL WELLNESS LLC
Entity Type:Organization
Organization Name:REVIVE MENTAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JYNNAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:208-922-8298
Mailing Address - Street 1:1200 N MAIN ST UNIT 1623
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-5065
Mailing Address - Country:US
Mailing Address - Phone:208-398-3351
Mailing Address - Fax:
Practice Address - Street 1:200 N 23RD ST STE 106
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4969
Practice Address - Country:US
Practice Address - Phone:208-398-3351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2023-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty