Healthcare Provider Details

I. General information

NPI: 1386951481
Provider Name (Legal Business Name): JILL RENAE NICKOLOFF P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N 27TH ST
BILLINGS MT
59101-0760
US

IV. Provider business mailing address

123 S 27TH ST
BILLINGS MT
59101-4227
US

V. Phone/Fax

Practice location:
  • Phone: 800-332-7156
  • Fax: 406-247-6242
Mailing address:
  • Phone: 406-247-3350
  • Fax: 406-651-6406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number622
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: