Healthcare Provider Details

I. General information

NPI: 1669152005
Provider Name (Legal Business Name): JANA MARIE MONTGOMERY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 EAST COEUR D'ALENE AVENUE
COEUR D'ALENE ID
83814
US

IV. Provider business mailing address

12208 N DIAMOND DR
HAYDEN ID
83835-7909
US

V. Phone/Fax

Practice location:
  • Phone: 208-551-1575
  • Fax:
Mailing address:
  • Phone: 316-990-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-2477
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: