Healthcare Provider Details

I. General information

NPI: 1467986216
Provider Name (Legal Business Name): JILL SHAVER ACC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 2ND AVENUE WN SUITE #100
KALISPELL MT
59901
US

IV. Provider business mailing address

285 2ND AVENUE WN SUITE #100
KALISPELL MT
59901
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-0112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16383
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: