Provider Demographics
NPI:1841668761
Name:TAYLOR, JERILYN (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:JERILYN
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:MS
Other - First Name:JERILYN
Other - Middle Name:
Other - Last Name:KEJICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACADC
Mailing Address - Street 1:615 HOOPES AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6106
Mailing Address - Country:US
Mailing Address - Phone:208-542-0352
Mailing Address - Fax:208-542-0359
Practice Address - Street 1:615 HOOPES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-6106
Practice Address - Country:US
Practice Address - Phone:208-542-0352
Practice Address - Fax:208-542-0359
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6094101YM0800X
ID03 197101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1841668761OtherNPI