Provider Demographics
NPI:1669844320
Name:BAZZLE, JACQUELINE (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BAZZLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:CHERI
Other - Last Name:SMITHEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:6126 W STATE ST # 409
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2741
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:208-287-9426
Practice Address - Street 1:6126 W STATE ST # 409
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2741
Practice Address - Country:US
Practice Address - Phone:208-376-7083
Practice Address - Fax:208-321-5069
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC5973101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC5973OtherSTATE LICENSE