Provider Demographics
NPI:1548239833
Name:MONTGOMERY, JEAN M (NP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:M
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-2347
Mailing Address - Country:US
Mailing Address - Phone:276-889-7621
Mailing Address - Fax:276-889-7695
Practice Address - Street 1:75 ROGERS ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4501
Practice Address - Country:US
Practice Address - Phone:276-889-7621
Practice Address - Fax:276-889-7695
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024049137363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics