Provider Demographics
NPI:1578965422
Name:REYES, JORGE DOMINGO (MS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:DOMINGO
Last Name:REYES
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 N. WORLD CUP LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-514-9497
Mailing Address - Fax:
Practice Address - Street 1:5700 E. FRANKLIN RD.
Practice Address - Street 2:SUITE 220-I
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-514-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5723101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health