Healthcare Provider Details

I. General information

NPI: 1689161697
Provider Name (Legal Business Name): JENNIE EILEEN BONDURANT ATS, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 N MERIDIAN RD
KALISPELL MT
59901-3095
US

IV. Provider business mailing address

PO BOX 7115
KALISPELL MT
59904-0115
US

V. Phone/Fax

Practice location:
  • Phone: 406-756-6453
  • Fax: 406-756-8546
Mailing address:
  • Phone: 406-756-6453
  • Fax: 406-756-8546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30018
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: