Provider Demographics
NPI:1467605642
Name:JEPPESEN, AMY K (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:JEPPESEN
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 1:8950 W EMERALD ST
Mailing Address - Street 2:SUITE 178
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4854
Mailing Address - Country:US
Mailing Address - Phone:208-376-7083
Mailing Address - Fax:208-321-5069
Practice Address - Street 1:8950 W EMERALD ST
Practice Address - Street 2:SUITE 178
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4854
Practice Address - Country:US
Practice Address - Phone:208-376-7083
Practice Address - Fax:208-321-5069
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT374774-3501322D00000X
IDLCSW-279361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children