Provider Demographics
NPI:1962019513
Name:CROCKER-OSWALD, JESSICA ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:CROCKER-OSWALD
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 1:4438 N SUPAI AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3671
Mailing Address - Country:US
Mailing Address - Phone:208-392-0006
Mailing Address - Fax:
Practice Address - Street 1:1005 E PARK BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7722
Practice Address - Country:US
Practice Address - Phone:208-392-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40036104100000X
ID440691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker