Provider Demographics
NPI:1811374432
Name:ACJCS
Entity Type:Organization
Organization Name:ACJCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEAGRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-287-5624
Mailing Address - Street 1:400 N BENJAMIN LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5094
Mailing Address - Country:US
Mailing Address - Phone:208-387-5600
Mailing Address - Fax:
Practice Address - Street 1:400 N BENJAMIN LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5094
Practice Address - Country:US
Practice Address - Phone:208-387-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID22251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health