Provider Demographics
NPI:1295977049
Name:MONTGOMERY, JILL MARIE (LMP)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:MARIE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:LMP
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 2982
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-2982
Mailing Address - Country:US
Mailing Address - Phone:360-670-8155
Mailing Address - Fax:
Practice Address - Street 1:3319 BENNETT DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1115
Practice Address - Country:US
Practice Address - Phone:360-670-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60064158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist