Provider Demographics
NPI:1770701609
Name:KOVNICK, JEFFREY ARNOLD (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ARNOLD
Last Name:KOVNICK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6106
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6106
Mailing Address - Country:US
Mailing Address - Phone:801-910-5822
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 6106
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-6106
Practice Address - Country:US
Practice Address - Phone:801-910-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT184995-12052084P0804X
IDM-171912084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF42172Medicare UPIN