Provider Demographics
NPI:1104687730
Name:WADDELL, JERI L (LCPC)
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:L
Last Name:WADDELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8300
Mailing Address - Country:US
Mailing Address - Phone:406-274-8784
Mailing Address - Fax:
Practice Address - Street 1:3209 WASHBURN ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8300
Practice Address - Country:US
Practice Address - Phone:406-274-8784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT56468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional