Healthcare Provider Details

I. General information

NPI: 1336980366
Provider Name (Legal Business Name): JONATHAN MICHEAL HAGEN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 12TH AVE S
GREAT FALLS MT
59405-4607
US

IV. Provider business mailing address

509 40TH ST N
GREAT FALLS MT
59405-1209
US

V. Phone/Fax

Practice location:
  • Phone: 406-453-8885
  • Fax:
Mailing address:
  • Phone: 406-459-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27102
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: