Provider Demographics
NPI:1679759500
Name:VENBRUX, JACK A (MA, LCPC, LMHC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:VENBRUX
Suffix:
Gender:M
Credentials:MA, LCPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2604
Mailing Address - Country:US
Mailing Address - Phone:509-336-5972
Mailing Address - Fax:
Practice Address - Street 1:1103 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2604
Practice Address - Country:US
Practice Address - Phone:509-336-5972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60249089101YM0800X
IDLCPC-6701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH60249089OtherPROVIDER LICENSE WA STATE
IDLCPC-6701OtherPROVIDER LICENSE STATE OF IDAHO