Active NPI
Jessie A Bacon, LCSW
- Clinical Social Worker
- Fort Hall, ID
National Provider Identifier
1750507604
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- LCSW-32218
- Practice address
- Mission Road Blding 248
Fort Hall Indian Agency
Fort Hall, ID 83203 - Phone
- (208) 237-5631
- Fax
- (208) 237-5796
- NPI assigned
- Apr 18, 2007
- Last updated
- Mar 18, 2024
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | LCSW-32218 | ID | Primary |
Addresses
Primary practice location
Mission Road Blding 248
Fort Hall Indian Agency
Fort Hall, ID 83203
Mailing address
1068 E Reservation Rich LN
Blackfoot, ID 83221-7052
Phone (208) 681-6980
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID, TX
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 2
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Shoshone Bannock Tribes, Inc | Current | Accepting new patients | |
| Shoshone-Bannock Community Health Center | Past | Accepting new patients |
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Shoshone-Bannock Community Health Center
- Clinic/Center
- Fort Hall, ID
- NPI 1225414519
TX
-
dba Shoshone-Bannock Tribes
- Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
- Fort Hall, ID
- NPI 1225570716
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176854400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1710720000000",
"number": "1750507604",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1068 E RESERVATION RICH LN",
"city": "BLACKFOOT",
"state": "ID",
"postal_code": "832217052",
"telephone_number": "208-681-6980"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "MISSION ROAD BLDING 248",
"address_2": "FORT HALL INDIAN AGENCY",
"city": "FORT HALL",
"state": "ID",
"postal_code": "83203",
"telephone_number": "208-237-5631",
"fax_number": "208-237-5796"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BACON",
"first_name": "JESSIE",
"middle_name": "A",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-04-18",
"last_updated": "2024-03-18",
"certification_date": "2024-03-18",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "ID",
"license": "LCSW-32218",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Hall, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.