Provider Demographics
NPI:1982761946
Name:MONTGOMERY, JEFFREY A (MSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 MILL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-7744
Mailing Address - Country:US
Mailing Address - Phone:740-687-9389
Mailing Address - Fax:740-689-9518
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9718
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:740-789-9518
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI58821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMOSW21092Medicare ID - Type Unspecified