Provider Demographics
NPI:1134652662
Name:FRAGA, JENNIFER AMANDA (MSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:AMANDA
Last Name:FRAGA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:AMANDA
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2272 NE KELLY ANN CT
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-8298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 S WILLSON AVE STE 9
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4610
Practice Address - Country:US
Practice Address - Phone:917-716-7829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
L122241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator