Provider Demographics
NPI:1639531288
Name:BURLAGE, JENNIFER (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BURLAGE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2613 N 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5415
Mailing Address - Country:US
Mailing Address - Phone:208-867-1856
Mailing Address - Fax:
Practice Address - Street 1:1720 N WESTGATE DR STE A1
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7164
Practice Address - Country:US
Practice Address - Phone:208-334-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-4810106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist