Healthcare Provider Details

I. General information

NPI: 1437782810
Provider Name (Legal Business Name): JACOB WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 CENTENNIAL AVE
BUTTE MT
59701-2870
US

IV. Provider business mailing address

445 CENTENNIAL AVE
BUTTE MT
59701-2870
US

V. Phone/Fax

Practice location:
  • Phone: 406-723-4075
  • Fax:
Mailing address:
  • Phone: 406-723-4075
  • Fax: 406-496-6035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-APRN-LIC-157870
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: