Provider Demographics
NPI:1417004086
Name:MONTGOMERY, JEWEL B (RN)
Entity Type:Individual
Prefix:MRS
First Name:JEWEL
Middle Name:B
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:JEWEL
Other - Middle Name:B
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 3235
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30061-3235
Mailing Address - Country:US
Mailing Address - Phone:770-427-5114
Mailing Address - Fax:770-427-6396
Practice Address - Street 1:859 ECTOR CHASE NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4788
Practice Address - Country:US
Practice Address - Phone:770-427-5114
Practice Address - Fax:770-427-6396
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN100039163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical