Provider Demographics
NPI:1003591751
Name:MONTAGUE, JARED THAYER (ALC, NCC)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:THAYER
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:ALC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 2ND AVE S APT 328
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-2075
Mailing Address - Country:US
Mailing Address - Phone:423-440-3836
Mailing Address - Fax:
Practice Address - Street 1:1117 22ND ST S STE 208
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-2813
Practice Address - Country:US
Practice Address - Phone:205-319-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04482101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty