Provider Demographics
NPI:1558818906
Name:FORD, JENNIFER K (CADC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:FORD
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 11TH AVE E
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-5368
Mailing Address - Country:US
Mailing Address - Phone:208-934-8461
Mailing Address - Fax:
Practice Address - Street 1:605 11TH AVE E
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5368
Practice Address - Country:US
Practice Address - Phone:208-934-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10245101YA0400X
ID11659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)