Healthcare Provider Details

I. General information

NPI: 1568734804
Provider Name (Legal Business Name): JADE MALCOLM APRN-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 AVENUE B SUITE 3100
SCOTTSBLUFF NE
69361-4617
US

IV. Provider business mailing address

3911 AVENUE B SUITE 3100
SCOTTSBLUFF NE
69361-4617
US

V. Phone/Fax

Practice location:
  • Phone: 308-635-3033
  • Fax:
Mailing address:
  • Phone: 308-635-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number111330
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: