Provider Demographics
NPI:1578834586
Name:JEAN D BALLOU PC
Entity Type:Organization
Organization Name:JEAN D BALLOU PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-543-9566
Mailing Address - Street 1:210 N HIGGINS AVE STE 314
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4443
Mailing Address - Country:US
Mailing Address - Phone:406-543-9566
Mailing Address - Fax:
Practice Address - Street 1:210 N HIGGINS AVE STE 314
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4443
Practice Address - Country:US
Practice Address - Phone:406-543-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT27LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0503295Medicaid
MT0000071350OtherBLUE CROSS BLUE SHIELD
MT0000071350OtherBLUE CROSS BLUE SHIELD