Basic Information
| Provider Information | |||||||||
| NPI: | 1851760615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLYTHE | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 427 | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598650427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454409 | ||||||||
| Practice Location | |||||||||
| Address1: | 35401 MISSION DRIVE | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598653649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | BBH-PCLC-LIC-30656 | MT | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 1087 | MT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 9901567 | 05 | MT | MEDICAID |