Provider Demographics
NPI:1912205295
Name:MURDOCK, JONATHAN RILEY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:RILEY
Last Name:MURDOCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RILEY
Other - Middle Name:
Other - Last Name:MURDOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:1846 1ST ST # 1011
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4415
Mailing Address - Country:US
Mailing Address - Phone:208-254-1882
Mailing Address - Fax:
Practice Address - Street 1:1810 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5072
Practice Address - Country:US
Practice Address - Phone:208-538-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-445391041C0700X, 1041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator