Provider Demographics
NPI:1770813388
Name:RICKS, JESSICA LYNN (LSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:RICKS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 CAPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5312
Mailing Address - Country:US
Mailing Address - Phone:208-441-8284
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST STE C
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-524-1278
Practice Address - Fax:208-529-3184
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-28696104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker