Provider Demographics
NPI:1295259638
Name:MONTGOMERY, JILLIAN (MA, LPCC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 COMMERCE DR.
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:612-767-7222
Mailing Address - Fax:
Practice Address - Street 1:721 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:612-728-5301
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2582101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health