Provider Demographics
NPI:1679284822
Name:GILKERSON, JONATHAN RAY (LMSW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RAY
Last Name:GILKERSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 W NORTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7126
Mailing Address - Country:US
Mailing Address - Phone:208-327-0504
Mailing Address - Fax:
Practice Address - Street 1:8050 W NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7126
Practice Address - Country:US
Practice Address - Phone:208-327-0504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID42310104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker