Provider Demographics
NPI:1609158781
Name:TUTTLE, JENNIFER RIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RIAN
Last Name:TUTTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RIAN
Other - Last Name:MCLUSKIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:9705 N SHAW ST
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9716
Mailing Address - Country:US
Mailing Address - Phone:208-625-9981
Mailing Address - Fax:
Practice Address - Street 1:9705 N SHAW ST
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9716
Practice Address - Country:US
Practice Address - Phone:208-625-9981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-316491041C0700X
ID316491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1609158781Medicaid