Provider Demographics
NPI:1174682520
Name:BOSLOUGH, JEANNIE ANN
Entity Type:Individual
Prefix:MRS
First Name:JEANNIE
Middle Name:ANN
Last Name:BOSLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JEANNIE
Other - Middle Name:
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:6007 ST MORITZ DR APT H
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-3284
Mailing Address - Country:US
Mailing Address - Phone:406-730-1235
Mailing Address - Fax:
Practice Address - Street 1:6007 ST MORITZ DR APT H
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-3284
Practice Address - Country:US
Practice Address - Phone:406-730-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0502814Medicaid
MT70660OtherBLUE CROSS-SHIELD OF MT
MT70660OtherBLUE CROSS-SHIELD OF MT