Healthcare Provider Details

I. General information

NPI: 1528738002
Provider Name (Legal Business Name): JESS NP FAMILY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 03/15/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S CENTRAL AVE
MALTA MT
59538-0581
US

IV. Provider business mailing address

PO BOX 581
MALTA MT
59538-0581
US

V. Phone/Fax

Practice location:
  • Phone: 406-654-1953
  • Fax: 406-654-5204
Mailing address:
  • Phone: 406-654-1953
  • Fax: 406-654-5204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSICA MARIE DOMIRE
Title or Position: OWNER
Credential: FNP-C
Phone: 406-654-1953