Provider Demographics
NPI:1811002363
Name:JENNI, MARY A
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:JENNI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:HOVLAND
Other - Last Name:JENNI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:137 CRESTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1437
Mailing Address - Country:US
Mailing Address - Phone:406-829-1515
Mailing Address - Fax:
Practice Address - Street 1:1640 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-829-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT52010OtherBLUE CROSS BLUE SHIELD
MT0492422Medicaid
MT5080Medicare ID - Type Unspecified