Healthcare Provider Details

I. General information

NPI: 1497464168
Provider Name (Legal Business Name): JAYDEE LYNN WEATHERWAX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S RUSSELL ST
MISSOULA MT
59801-3629
US

IV. Provider business mailing address

2100 STEPHENS AVE STE 105
MISSOULA MT
59801-6607
US

V. Phone/Fax

Practice location:
  • Phone: 406-829-9515
  • Fax:
Mailing address:
  • Phone: 406-829-9515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-SWLC-LIC-72913
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: