Provider Demographics
NPI:1558869909
Name:POPE, JASON KENDALL (LMSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KENDALL
Last Name:POPE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 ALDER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-9765
Mailing Address - Country:US
Mailing Address - Phone:208-568-0826
Mailing Address - Fax:208-665-5795
Practice Address - Street 1:4825 ALDER CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-9765
Practice Address - Country:US
Practice Address - Phone:208-568-0826
Practice Address - Fax:208-665-5795
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-37223104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1366794224Medicaid