Provider Demographics
NPI:1891115499
Name:WHAITE, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WHAITE
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 1:8515 E DROVER LOOP
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-8506
Mailing Address - Country:US
Mailing Address - Phone:208-505-8657
Mailing Address - Fax:
Practice Address - Street 1:136 S ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6541
Practice Address - Country:US
Practice Address - Phone:208-254-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ID40339104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health