Healthcare Provider Details

I. General information

NPI: 1194136010
Provider Name (Legal Business Name): LUKE JARVIS JACKSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 29TH ST S
GREAT FALLS MT
59405-5353
US

IV. Provider business mailing address

543 W 2700 N
NEPHI UT
84648-3004
US

V. Phone/Fax

Practice location:
  • Phone: 409-454-2171
  • Fax:
Mailing address:
  • Phone: 435-531-9643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNUR-RN-LIC-74240
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: