Provider Demographics
NPI:1043701766
Name:CUSTER, JESSICA LAMAE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LAMAE
Last Name:CUSTER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4420
Mailing Address - Country:US
Mailing Address - Phone:509-969-9254
Mailing Address - Fax:
Practice Address - Street 1:1200 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2660
Practice Address - Country:US
Practice Address - Phone:208-664-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID37733104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker