Provider Demographics
NPI:1407518087
Name:MATHIS, JESSE ALLEGRA (LPC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:ALLEGRA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10673 W LAKE HAZEL RD # 50
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5453
Mailing Address - Country:US
Mailing Address - Phone:208-230-4461
Mailing Address - Fax:
Practice Address - Street 1:6932 S HUNT WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1564
Practice Address - Country:US
Practice Address - Phone:208-230-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC8353101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health