Provider Demographics
NPI:1326446444
Name:MONTGOMERY, JENNIFER HOPE (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HOPE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 WACCAMAW MEDICAL PARK DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5206
Mailing Address - Country:US
Mailing Address - Phone:843-251-3672
Mailing Address - Fax:
Practice Address - Street 1:119 WACCAMAW MEDICAL PARK DR UNIT B
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5206
Practice Address - Country:US
Practice Address - Phone:843-251-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist