Provider Demographics
NPI:1821571969
Name:PERRY, JESSICA MAXFIELD (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAXFIELD
Last Name:PERRY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-0450
Mailing Address - Country:US
Mailing Address - Phone:208-462-3074
Mailing Address - Fax:
Practice Address - Street 1:50 MIRACLE LANE
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83622-0450
Practice Address - Country:US
Practice Address - Phone:208-462-3074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34640104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker