Provider Demographics
NPI:1689410508
Name:DIRIENZO, JESSICA ELIZABETH
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:DIRIENZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 TOWN CENTER A5
Mailing Address - Street 2:PO BOX 160443
Mailing Address - City:BIG SKY
Mailing Address - State:MT
Mailing Address - Zip Code:59716
Mailing Address - Country:US
Mailing Address - Phone:970-409-7730
Mailing Address - Fax:
Practice Address - Street 1:223 TOWN CENTER A5
Practice Address - Street 2:PO BOX 160443
Practice Address - City:BIG SKY
Practice Address - State:MT
Practice Address - Zip Code:59716
Practice Address - Country:US
Practice Address - Phone:970-409-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-720991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical