Provider Demographics
NPI:1770224644
Name:LOVELACE, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W WILLIAMS ST STE G
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3564
Mailing Address - Country:US
Mailing Address - Phone:208-991-0222
Mailing Address - Fax:
Practice Address - Street 1:1011 W WILLIAMS ST STE G
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3564
Practice Address - Country:US
Practice Address - Phone:208-991-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-8557101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health