Provider Demographics
NPI:1811572738
Name:MONTGOMERY, JACQUETTA SHANAE (MA)
Entity Type:Individual
Prefix:MS
First Name:JACQUETTA
Middle Name:SHANAE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 E NORTH ST STE GG
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1272
Mailing Address - Country:US
Mailing Address - Phone:864-729-9851
Mailing Address - Fax:
Practice Address - Street 1:2320 E NORTH ST STE GG
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1272
Practice Address - Country:US
Practice Address - Phone:864-729-9851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care