Provider Demographics
NPI:1245431857
Name:MONTGOMERY, JENNIFER MARY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARY
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 W. CACTUS RD.
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-937-5090
Mailing Address - Fax:623-937-5349
Practice Address - Street 1:6815 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5313
Practice Address - Country:US
Practice Address - Phone:623-937-5090
Practice Address - Fax:623-937-5349
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-117951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW-11795Medicaid