Provider Demographics
NPI:1477858785
Name:ATKINSON, JACOB (PSYD, ATR)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ATKINSON
Suffix:
Gender:M
Credentials:PSYD, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6568 S FEDERAL WAY
Mailing Address - Street 2:BOX 235
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-9277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:671 E RIVERPARK LN STE 220
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6559
Practice Address - Country:US
Practice Address - Phone:208-344-2071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5800101YP2500X, 101YP2500X
IDPSY-203023103TC1900X
AK652101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling