Provider Demographics
NPI:1841045317
Name:MIKELONIS, JESSICA SARA (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SARA
Last Name:MIKELONIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SARA
Other - Last Name:VALLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1111 S ORCHARD ST STE 245
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1964
Mailing Address - Country:US
Mailing Address - Phone:208-867-9403
Mailing Address - Fax:
Practice Address - Street 1:1111 S ORCHARD ST STE 245
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1964
Practice Address - Country:US
Practice Address - Phone:208-867-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2646101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional