Healthcare Provider Details

I. General information

NPI: 1962599720
Provider Name (Legal Business Name): JODEAN NICOLETTE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45280 SEELEY DR
LA QUINTA CA
92253-6834
US

IV. Provider business mailing address

401 RAILROAD ST W
MISSOULA MT
59802-4109
US

V. Phone/Fax

Practice location:
  • Phone: 760-834-7920
  • Fax: 760-834-7921
Mailing address:
  • Phone: 406-258-4789
  • Fax: 406-258-4732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA66309
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number68166
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: