Provider Demographics
NPI:1679622393
Name:FRONTIER PSYCHOLOGICAL ASSOCIATES, L C
Entity type:Organization
Organization Name:FRONTIER PSYCHOLOGICAL ASSOCIATES, L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIET
Authorized Official - Middle Name:L
Authorized Official - Last Name:JETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-789-6773
Mailing Address - Street 1:724 FRONT STREET
Mailing Address - Street 2:SUITE 230
Mailing Address - City:EVANSTON
Mailing Address - State:WV
Mailing Address - Zip Code:82930
Mailing Address - Country:US
Mailing Address - Phone:307-789-6773
Mailing Address - Fax:307-789-3244
Practice Address - Street 1:724 FRONT STREET
Practice Address - Street 2:SUITE 230
Practice Address - City:EVANSTON
Practice Address - State:WV
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-6773
Practice Address - Fax:307-789-3244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110414403Medicaid