Healthcare Provider Details

I. General information

NPI: 1376265744
Provider Name (Legal Business Name): JESSICA CONNER NCC, PCLC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SOUTH AVE W STE E
MISSOULA MT
59801-8011
US

IV. Provider business mailing address

423 W CENTRAL AVE
MISSOULA MT
59801-6813
US

V. Phone/Fax

Practice location:
  • Phone: 406-624-9194
  • Fax:
Mailing address:
  • Phone: 808-387-1681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-PCLC-LIC-55023
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number224241
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: