Healthcare Provider Details

I. General information

NPI: 1730314493
Provider Name (Legal Business Name): JENNIFER ANN CARLSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N HIGGINS AVE STE 204.2B
MISSOULA MT
59802-4437
US

IV. Provider business mailing address

5108 VILLAGE VIEW WAY APT 7
MISSOULA MT
59803-3400
US

V. Phone/Fax

Practice location:
  • Phone: 917-769-9609
  • Fax:
Mailing address:
  • Phone: 917-769-9609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number011099
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-58544
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080179
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: