Provider Demographics
NPI:1619438546
Name:MONTGOMERY, JEANIE MARIE (BS, LPN, LAC)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:MARIE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:BS, LPN, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1807 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1142
Practice Address - Country:US
Practice Address - Phone:605-642-7093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional