Provider Demographics
NPI:1578859146
Name:STOCKETT, JEREMY J (LCSW)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:STOCKETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 PARKCENTRE WAY STE 7
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1748
Mailing Address - Country:US
Mailing Address - Phone:208-442-7791
Mailing Address - Fax:208-442-7792
Practice Address - Street 1:915 PARKCENTRE WAY STE 7
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1748
Practice Address - Country:US
Practice Address - Phone:208-442-7791
Practice Address - Fax:208-442-7792
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-309691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical