Healthcare Provider Details

I. General information

NPI: 1922631357
Provider Name (Legal Business Name): JASON WILLHARDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

3687 VETERANS DR
FORT HARRISON MT
59636-9700
US

IV. Provider business mailing address

3687 VETERANS DR
FORT HARRISON MT
59636-9700
US

V. Phone/Fax

Practice location:
  • Phone: 877-468-8387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberCLS-CLS-LIC-1663
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: