Provider Demographics
NPI:1326723826
Name:ROBERTY, JENICA (MS)
Entity Type:Individual
Prefix:
First Name:JENICA
Middle Name:
Last Name:ROBERTY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 S MONTANA AVE APT D3
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5391
Mailing Address - Country:US
Mailing Address - Phone:406-580-0877
Mailing Address - Fax:
Practice Address - Street 1:950 STONERIDGE DR STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7063
Practice Address - Country:US
Practice Address - Phone:406-624-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT63304101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health