Provider Demographics
NPI:1740255264
Name:WEADICK, JILL REID (LCPC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:REID
Last Name:WEADICK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:DARCY
Other - Last Name:REID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:6133 S MARBRISA LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8243
Mailing Address - Country:US
Mailing Address - Phone:208-569-8288
Mailing Address - Fax:
Practice Address - Street 1:1075 S UTAH AVE STE 354
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3320
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:208-529-5778
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-19
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-2986101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health