Provider Demographics
NPI:1699413757
Name:WILD LIFE COMMUNITY COUNSELING PLLC
Entity Type:Organization
Organization Name:WILD LIFE COMMUNITY COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-416-3850
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-0172
Mailing Address - Country:US
Mailing Address - Phone:208-416-3850
Mailing Address - Fax:
Practice Address - Street 1:264 BLACK MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-5308
Practice Address - Country:US
Practice Address - Phone:208-416-3850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty