Healthcare Provider Details

I. General information

NPI: 1265752034
Provider Name (Legal Business Name): MOUNTAIN HOME MONTANA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 01/13/2026
Certification Date: 01/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 23RD AVE
MISSOULA MT
59803-1137
US

IV. Provider business mailing address

4720 23RD AVE
MISSOULA MT
59803-1137
US

V. Phone/Fax

Practice location:
  • Phone: 406-541-4663
  • Fax: 406-541-4662
Mailing address:
  • Phone: 406-541-4663
  • Fax: 406-541-4662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number13491
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number709LCSW
License Number StateMT
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number13491
License Number StateMT

VIII. Authorized Official

Name: GRETA JERNBERG
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 406-541-4663