Provider Demographics
NPI:1851760615
Name:BLYTHE, JEANETTE K
Entity Type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:K
Last Name:BLYTHE
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:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-0880
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:406-745-4409
Practice Address - Street 1:35401 MISSION DRIVE
Practice Address - Street 2:
Practice Address - City:SAINT IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-3649
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:406-745-4409
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-30656101YP2500X
MTBBH-LAC-LIC-1087101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT9901567Medicaid