Provider Demographics
NPI:1891447751
Name:NIELSON, KENDRA JEAN
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:JEAN
Last Name:NIELSON
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 1:14331 CREGO ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-4815
Mailing Address - Country:US
Mailing Address - Phone:208-757-0067
Mailing Address - Fax:
Practice Address - Street 1:1901 N LAKES PL STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5939
Practice Address - Country:US
Practice Address - Phone:208-890-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8629101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health