Provider Demographics
NPI:1801371976
Name:MONTGOMERY, JENNIFER SUE (CT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19883 STATE ROUTE 772
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9299
Mailing Address - Country:US
Mailing Address - Phone:740-222-1124
Mailing Address - Fax:
Practice Address - Street 1:14572 US HIGHWAY 23 STE A
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9448
Practice Address - Country:US
Practice Address - Phone:740-947-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)