Provider Demographics
NPI:1710667142
Name:PACIFIC MENTAL HEALTH IDAHO LLC
Entity Type:Organization
Organization Name:PACIFIC MENTAL HEALTH IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-361-2273
Mailing Address - Street 1:5108 196TH ST SW STE 350
Mailing Address - Street 2:C/O RXDX MEDICAL BILLING SERVICES LLC, STE 310
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6169
Mailing Address - Country:US
Mailing Address - Phone:425-361-2273
Mailing Address - Fax:
Practice Address - Street 1:1617 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5029
Practice Address - Country:US
Practice Address - Phone:425-582-2041
Practice Address - Fax:425-527-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty