Provider Demographics
NPI:1568898013
Name:WOOD, JERRILYNNE (LCPC-4457)
Entity Type:Individual
Prefix:
First Name:JERRILYNNE
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:LCPC-4457
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5919
Mailing Address - Country:US
Mailing Address - Phone:208-552-2109
Mailing Address - Fax:
Practice Address - Street 1:111 E 16TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5919
Practice Address - Country:US
Practice Address - Phone:208-552-2109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC4457101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health