Provider Demographics
NPI:1952823148
Name:JENKINS, AMY MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 PYRENEES LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6045
Mailing Address - Country:US
Mailing Address - Phone:720-442-2007
Mailing Address - Fax:
Practice Address - Street 1:1115 W IRONWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4937
Practice Address - Country:US
Practice Address - Phone:208-665-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO009928361041C0700X
IDLCSW366851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical