Provider Demographics
NPI:1740962315
Name:KNICKREHM, JACKELLE N (LMSW)
Entity type:Individual
Prefix:MS
First Name:JACKELLE
Middle Name:N
Last Name:KNICKREHM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JACKELLE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 S ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-254-1112
Mailing Address - Fax:208-939-9110
Practice Address - Street 1:136 S ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-254-1112
Practice Address - Fax:208-939-9110
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-35335101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor