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: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 DENVER ST STE 100
WHITEFISH MT
59937-3498
US

IV. Provider business mailing address

704 13TH ST E., STE C, PMB# 660
WHITEFISH MT
59937
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