Provider Demographics
NPI:1770741407
Name:SAPP, JEANNETTE M (LMSW/ CADC)
Entity type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:M
Last Name:SAPP
Suffix:
Gender:F
Credentials:LMSW/ CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 N 1200 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5171
Mailing Address - Country:US
Mailing Address - Phone:208-604-3282
Mailing Address - Fax:
Practice Address - Street 1:303 N 12TH AVE
Practice Address - Street 2:204
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4746
Practice Address - Country:US
Practice Address - Phone:208-604-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1042003101YA0400X
IDLMSW-285001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10400000XMedicaid