Provider Demographics
NPI:1568674679
Name:GOULDSBERRY-WELLMAN, JENNIFER LYNN (ACT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:GOULDSBERRY-WELLMAN
Suffix:
Gender:F
Credentials:ACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 S 12TH ST W
Mailing Address - Street 2:APT. B
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4821
Mailing Address - Country:US
Mailing Address - Phone:406-239-6181
Mailing Address - Fax:
Practice Address - Street 1:900 S HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4100
Practice Address - Country:US
Practice Address - Phone:406-728-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other