Healthcare Provider Details

I. General information

NPI: 1023696218
Provider Name (Legal Business Name): JORDAN MCLAINE ICENOGGLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN MCLAIN ALBRECHT MD

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WESTWOOD DR STE G
HAMILTON MT
59840-2345
US

IV. Provider business mailing address

1224 W MAIN ST
HAMILTON MT
59840-2338
US

V. Phone/Fax

Practice location:
  • Phone: 406-375-4777
  • Fax: 406-375-4778
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMED-PHYS-LIC-148113
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: