Provider Demographics
NPI:1972134146
Name:FLORIAN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FLORIAN
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 1:2200 N BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5137
Mailing Address - Country:US
Mailing Address - Phone:208-906-4782
Mailing Address - Fax:
Practice Address - Street 1:2200 N BRANDON RD
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5137
Practice Address - Country:US
Practice Address - Phone:208-906-4782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID106S00000XMedicaid