Provider Demographics
NPI:1023444957
Name:PADRON, JORGE (CADC)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:PADRON
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 AMY LN
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4542
Mailing Address - Country:US
Mailing Address - Phone:208-589-4139
Mailing Address - Fax:
Practice Address - Street 1:543 3RD ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3909
Practice Address - Country:US
Practice Address - Phone:208-522-6925
Practice Address - Fax:208-522-6934
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID155101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)