Provider Demographics
NPI:1447477997
Name:CONNER, JACQUELINE L (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:L
Last Name:CONNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N. PRATTEN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MT
Mailing Address - Zip Code:59019-7148
Mailing Address - Country:US
Mailing Address - Phone:406-322-4789
Mailing Address - Fax:406-322-4789
Practice Address - Street 1:525 N. PRATTEN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MT
Practice Address - Zip Code:59019-7148
Practice Address - Country:US
Practice Address - Phone:406-322-4789
Practice Address - Fax:406-322-4789
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT660220OtherBCBS
MT0530725Medicaid