Provider Demographics
NPI:1578063616
Name:CHURCH, JEAN ALLISON (LCSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ALLISON
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALI
Other - Middle Name:
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:44959 SCHOOLHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLO
Mailing Address - State:MT
Mailing Address - Zip Code:59824-9449
Mailing Address - Country:US
Mailing Address - Phone:865-368-5298
Mailing Address - Fax:
Practice Address - Street 1:63917 US HWY- 93
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-3411
Practice Address - Country:US
Practice Address - Phone:865-368-5298
Practice Address - Fax:406-571-4008
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT298081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical