Provider Demographics
NPI:1306581988
Name:CERTA, JENNIFER (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CERTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JEN
Other - Middle Name:
Other - Last Name:CERTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, SWLC
Mailing Address - Street 1:400 W BROADWAY ST.
Mailing Address - Street 2:STE 101 - BOX #606
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802
Mailing Address - Country:US
Mailing Address - Phone:406-426-1194
Mailing Address - Fax:
Practice Address - Street 1:521 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4128
Practice Address - Country:US
Practice Address - Phone:406-426-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-597881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical