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General NPI Number Information
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NPI Number | 1053704726
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Entity Type | Organization
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Legal Business Name | JACKSON HOLE MENTAL HEALTH LLC
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Dates
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Enumeration Date | 03/05/2015
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Last Update Date | 04/01/2024
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Provider Practice Location Address
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Address Line | 310 E BROADWAY AVE
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City | JACKSON
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State | WY
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Zip | 83001-8636
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Country | US
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Telephone | 307-654-7003
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 13572
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City | JACKSON
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State | WY
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Zip | 83002-3572
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Country | US
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Telephone | 307-654-7003
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Fax |
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Authorized Official
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Title or Position | OWNER/EXECUTIVE DIRECTOR
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Name | LEAH C BLACK
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Credential | LCSW
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Telephone | 307-654-7003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 742
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License Number State | WY
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