Healthcare Provider Details

I. General information

NPI: 1508514852
Provider Name (Legal Business Name): AMBERLEE JORGENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WYOMING ST
MISSOULA MT
59801-1725
US

IV. Provider business mailing address

1201 NORTH AVE W
MISSOULA MT
59801-6601
US

V. Phone/Fax

Practice location:
  • Phone: 406-532-9700
  • Fax:
Mailing address:
  • Phone: 920-492-0726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-55303
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: