Healthcare Provider Details

I. General information

NPI: 1427513100
Provider Name (Legal Business Name): JESSIE VAILLANCOURT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 PERKINS CREEK RD
ALBERTON MT
59820
US

IV. Provider business mailing address

PO BOX 116
ALBERTON MT
59820-0116
US

V. Phone/Fax

Practice location:
  • Phone: 406-722-4451
  • Fax:
Mailing address:
  • Phone: 406-381-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-LMY-LIC-15823
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: