Provider Demographics
NPI:1245392448
Name:MONTAGUE, JENNY L (LSCW MSW)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:L
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:LSCW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 N ARROYO BLVD
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2644
Mailing Address - Country:US
Mailing Address - Phone:520-287-4713
Mailing Address - Fax:520-287-9794
Practice Address - Street 1:185 S MOORMAN AVE
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2700
Practice Address - Country:US
Practice Address - Phone:520-458-3932
Practice Address - Fax:520-458-3585
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLSCW 17211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ644775OtherAHCCCS