Provider Demographics
NPI:1174537203
Name:JONES, SUSAN KAY (LCSW28190)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:JONES
Suffix:
Gender:F
Credentials:LCSW28190
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 MORAN ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4337
Mailing Address - Country:US
Mailing Address - Phone:208-529-0329
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST STE B
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:208-529-8832
Practice Address - Fax:208-522-8725
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-28190101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149392OtherBLUE SHIELD
IDX5853OtherBLUE CROSS