Provider Demographics
NPI:1245684927
Name:IRVIN, JEREMY WAYNE (LCSW, MED)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:WAYNE
Last Name:IRVIN
Suffix:
Gender:M
Credentials:LCSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 E RENWICK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6467
Mailing Address - Country:US
Mailing Address - Phone:208-417-8428
Mailing Address - Fax:208-216-1434
Practice Address - Street 1:6003 W OVERLAND RD STE 105
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3075
Practice Address - Country:US
Practice Address - Phone:208-417-8428
Practice Address - Fax:208-216-1434
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-360601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical