Provider Demographics
NPI:1750047668
Name:JENNAWAY, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:JENNAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 BROADWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-2710
Mailing Address - Country:US
Mailing Address - Phone:406-259-1680
Mailing Address - Fax:
Practice Address - Street 1:554 PRONGHORN TRL STE A
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6082
Practice Address - Country:US
Practice Address - Phone:406-624-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician