Provider Demographics
NPI:1649793738
Name:KIRWAN, JESSICA RAE (LPC)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:RAE
Last Name:KIRWAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12033 W ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1761
Mailing Address - Country:US
Mailing Address - Phone:208-850-6419
Mailing Address - Fax:
Practice Address - Street 1:1529 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6570101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional