Healthcare Provider Details

I. General information

NPI: 1245392448
Provider Name (Legal Business Name): JENNY L MONTAGUE LSCW MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S MOORMAN AVE
SIERRA VISTA AZ
85635-2700
US

IV. Provider business mailing address

489 N ARROYO BLVD
NOGALES AZ
85621-2644
US

V. Phone/Fax

Practice location:
  • Phone: 520-458-3932
  • Fax: 520-458-3585
Mailing address:
  • Phone: 520-287-4713
  • Fax: 520-287-9794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCW 1721
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: