Provider Demographics
NPI:1336358266
Name:WALTZ, JENNIFER ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE
Last Name:WALTZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 SOUTH FOURTH STREET WEST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-370-0984
Mailing Address - Fax:
Practice Address - Street 1:519 S 4TH ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2629
Practice Address - Country:US
Practice Address - Phone:406-370-0984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT54751OtherBLUE CROSS BLUE SHIELD