MEDICARE: JACKSON STORM ASCM-CEP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Y00000X	Clinical Exercise Physiologist

General Provider Information

NPI Number	:	1548907033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON STORM ASCM-CEP

Provider Business Mailing Address
First Line	:	2908 3RD AVE S
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59405-3112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 RIVER DR S UNIT 4/5
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59405-1856
Country	:	US
Telephone Number	:	406-217-6770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2022
Last Update Date	:	05/16/2022

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