MEDICARE: JACKSON MICAH HOKANSON SWLC

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	1041C0700X	Clinical Social Worker	BBH-SWLC-LIC-33249	MT

General Provider Information

NPI Number	:	1669033551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON MICAH HOKANSON SWLC

Provider Business Mailing Address
First Line	:	175 HUTTON RANCH RD
Second Line	:	SUITE 103 #317
City	:	KALISPELL
State	:	MT
Zip	:	59901-2142
Country	:	US
Telephone Number	:	406-471-4296
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 E WASHINGTON ST STE A
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-3967
Country	:	US
Telephone Number	:	406-471-4296
Fax Number	:

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

Provider Enumeration Date	:	06/22/2019
Last Update Date	:	06/22/2019

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