Provider Demographics
NPI:1750456356
Name:MONTGOMERY, JERRY A (MSW ACSW LCSW)
Entity type:Individual
Prefix:MRS
First Name:JERRY
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MSW ACSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 BARKER RD
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360
Mailing Address - Country:US
Mailing Address - Phone:219-617-0526
Mailing Address - Fax:
Practice Address - Street 1:304 DETROIT ST
Practice Address - Street 2:SUITE A
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2473
Practice Address - Country:US
Practice Address - Phone:219-617-0526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002011A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN04355640072Medicare ID - Type Unspecified