Provider Demographics
NPI:1316312150
Name:JERNBERG, GRETA (LAC, LCSW)
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:JERNBERG
Suffix:
Gender:F
Credentials:LAC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 KENSINGTON AVE STE LL2
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5670
Mailing Address - Country:US
Mailing Address - Phone:406-529-2712
Mailing Address - Fax:
Practice Address - Street 1:800 KENSINGTON AVE STE LL2
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5670
Practice Address - Country:US
Practice Address - Phone:406-529-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT217271041C0700X
MTBBH-LAC-LIC-13136101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)