Provider Demographics
NPI:1417455668
Name:O'RULLIAN, JANA RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:RAE
Last Name:O'RULLIAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3573
Mailing Address - Country:US
Mailing Address - Phone:208-716-0384
Mailing Address - Fax:
Practice Address - Street 1:1069 SUMMERS DR STE B
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5335
Practice Address - Country:US
Practice Address - Phone:208-681-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-36797104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker