Provider Demographics
NPI:1477874246
Name:WILLISON, JEANNINE R (LAC)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:R
Last Name:WILLISON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-1928
Mailing Address - Country:US
Mailing Address - Phone:406-873-2155
Mailing Address - Fax:
Practice Address - Street 1:1210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CUT BANK
Practice Address - State:MT
Practice Address - Zip Code:59427-3152
Practice Address - Country:US
Practice Address - Phone:406-873-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1150101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)