| Jackson Hole Mental Health Llc | |
|
310 E Broadway Ave Jackson WY 83001-8636 | |
| (307) 654-7003 | |
| Not Available |
| Full Name | Jackson Hole Mental Health Llc |
|---|---|
| Speciality | Social Worker |
| Location | 310 E Broadway Ave, Jackson, Wyoming |
| Authorized Official Name and Position | Leah C Black (OWNER/EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 3076547003 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Jackson Hole Mental Health Llc Po Box 13572 Jackson WY 83002-3572 Ph: (307) 654-7003 | Jackson Hole Mental Health Llc 310 E Broadway Ave Jackson WY 83001-8636 Ph: (307) 654-7003 |
| NPI Number | 1053704726 |
|---|---|
| Provider Enumeration Date | 03/05/2015 |
| Last Update Date | 04/01/2024 |
| Certification Date | 04/01/2024 |
| Medicare PECOS PAC ID | 5496076002 |
|---|---|
| Medicare Enrollment ID | O20150608002987 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053704726 | NPI | - | NPPES |
| 130859900 | Medicaid | WY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 742 (Wyoming) | Primary |
| Provider Name | Leah Charlene Black |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1003107731 PECOS PAC ID: 6305167917 Enrollment ID: I20150617002976 |
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