Healthcare Provider Details

I. General information

NPI: 1700403243
Provider Name (Legal Business Name): PONDEROSA COUNSELING AND THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S CENTRAL AVE RM 304
WHITE SULPHUR SPRINGS MT
59645-9086
US

IV. Provider business mailing address

PO BOX 802
WHITE SULPHUR SPRINGS MT
59645-1802
US

V. Phone/Fax

Practice location:
  • Phone: 406-640-3242
  • Fax:
Mailing address:
  • Phone: 406-640-3242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KYLE JACOBSEN
Title or Position: OWNER
Credential: LCSW
Phone: 406-640-3242