Healthcare Provider Details

I. General information

NPI: 1497995047
Provider Name (Legal Business Name): TRACI KATHLEEN JASNICKI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 ELKHORN ROAD
SEELEY LAKE MT
59868-1486
US

IV. Provider business mailing address

PO BOX 1486
SEELEY LAKE MT
59868-1486
US

V. Phone/Fax

Practice location:
  • Phone: 406-210-3566
  • Fax:
Mailing address:
  • Phone: 406-210-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number31049
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: