Healthcare Provider Details

I. General information

NPI: 1700764974
Provider Name (Legal Business Name): JOURDAN CARLSON STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 CRESTVIEW DR UNIT 104
BIGFORK MT
59911-3559
US

IV. Provider business mailing address

439 GRAND DR # 142
BIGFORK MT
59911-3614
US

V. Phone/Fax

Practice location:
  • Phone: 106-393-8083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: