Provider Demographics
NPI:1417019027
Name:JANS WORTELBOER, HETTIE (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:HETTIE
Middle Name:
Last Name:JANS WORTELBOER
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2137
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-4708
Mailing Address - Country:US
Mailing Address - Phone:406-223-0206
Mailing Address - Fax:406-222-1444
Practice Address - Street 1:109 E LEWIS ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3112
Practice Address - Country:US
Practice Address - Phone:406-223-0206
Practice Address - Fax:406-222-1444
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC 1112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0256841Medicaid