Provider Demographics
NPI:1760504310
Name:LEARY, JENI E (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENI
Middle Name:E
Last Name:LEARY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:MT
Mailing Address - Zip Code:59632-0666
Mailing Address - Country:US
Mailing Address - Phone:406-439-6786
Mailing Address - Fax:
Practice Address - Street 1:40 HANGING WALL ROAD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632
Practice Address - Country:US
Practice Address - Phone:406-439-6786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT522LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT$$$$$$$$$Medicaid