Provider Demographics
NPI:1417001579
Name:MONTY, JEAN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:M
Last Name:MONTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W62 N248 WASHINGTON AVENUE
Mailing Address - Street 2:SUITE # 207
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012
Mailing Address - Country:US
Mailing Address - Phone:262-375-1116
Mailing Address - Fax:262-375-1071
Practice Address - Street 1:W62 N248 WASHINGTON AVENUE
Practice Address - Street 2:SUITE # 207
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:262-375-1071
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1880057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39609400Medicaid