Provider Demographics
NPI:1790853927
Name:MINKOFF, JONATHAN ROY (LCPC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROY
Last Name:MINKOFF
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11648 EVA LANE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-9716
Mailing Address - Country:US
Mailing Address - Phone:208-453-2840
Mailing Address - Fax:208-453-2840
Practice Address - Street 1:2020 BLAINE STREET
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-453-2840
Practice Address - Fax:208-453-2840
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-126101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017377OtherREGENCE BLUESHIELD OF ID
IDQ4608OtherBLUE CROSS OF IDAHO