Healthcare Provider Details

I. General information

NPI: 1467444786
Provider Name (Legal Business Name): JERRE M. MOUNT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2091 BOX BUTTE AVENUE SUITE 700
ALLIANCE NE
69301-4413
US

IV. Provider business mailing address

2091 BOX BUTTE AVENUE SUITE 700
ALLIANCE NE
69301-4413
US

V. Phone/Fax

Practice location:
  • Phone: 308-762-7244
  • Fax: 308-762-6657
Mailing address:
  • Phone: 308-762-7244
  • Fax: 308-762-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number606
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: