Provider Demographics
NPI:1558574178
Name:MONTGOMERY, JILL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 BRACKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3511
Mailing Address - Country:US
Mailing Address - Phone:512-443-6453
Mailing Address - Fax:512-440-1681
Practice Address - Street 1:610 RADAM LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1172
Practice Address - Country:US
Practice Address - Phone:512-444-8504
Practice Address - Fax:512-440-1681
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX072671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86441QOtherBLUE CROSS BLUE SHIELD