Basic Information
| Provider Information | |||||||||
| NPI: | 1023203650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7638 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598077638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Practice Location | |||||||||
| Address1: | 5549 OLD HWY 93 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598336545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062734923 | ||||||||
| FaxNumber: | 4068297863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 290 | MT | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 290 | 01 | MT | STATE LICENSE | OTHER |