Provider Demographics
NPI:1033577630
Name:MONTGOMERY, JENNIFER (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8753 CAMDEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-6945
Mailing Address - Country:US
Mailing Address - Phone:910-584-0934
Mailing Address - Fax:
Practice Address - Street 1:1915 CHAPEL HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1177
Practice Address - Country:US
Practice Address - Phone:919-246-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0101141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical