Provider Demographics
NPI:1558032698
Name:MITTELSTADT, JEN ACACIA (MSW)
Entity type:Individual
Prefix:
First Name:JEN
Middle Name:ACACIA
Last Name:MITTELSTADT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59624-0272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 N LAST CHANCE GULCH STE 213
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4179
Practice Address - Country:US
Practice Address - Phone:406-439-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-505261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical