Provider Demographics
NPI:1487433173
Name:BARDSLEY, JENNIFER RACICOT (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RACICOT
Last Name:BARDSLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 SHERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2662
Mailing Address - Country:US
Mailing Address - Phone:406-546-7443
Mailing Address - Fax:
Practice Address - Street 1:1032 SHERWOOD ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2662
Practice Address - Country:US
Practice Address - Phone:406-546-7443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-57473101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty