Provider Demographics
NPI:1760505747
Name:OSTERMILLER, JARED RYAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:RYAN
Last Name:OSTERMILLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 E 7TH N
Mailing Address - Street 2:STE 4
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3550
Mailing Address - Country:US
Mailing Address - Phone:208-359-9683
Mailing Address - Fax:208-359-9683
Practice Address - Street 1:242 E 7TH N
Practice Address - Street 2:STE 4
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3550
Practice Address - Country:US
Practice Address - Phone:208-359-9683
Practice Address - Fax:208-359-0889
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-13511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806530400Medicaid
ID806867300Medicaid
ID000010146334OtherBLUE SHIELD
IDL3688OtherBLUE CROSS