Healthcare Provider Details

I. General information

NPI: 1376572693
Provider Name (Legal Business Name): JEAN MARIE HOHM CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEAN MARIE MATTHEWS CPNP

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 FOUNDERS PARK DR SUITE 3
RAPID CITY SD
57701-8098
US

IV. Provider business mailing address

211 FOUNDERS PARK DR SUITE 3
RAPID CITY SD
57701-8098
US

V. Phone/Fax

Practice location:
  • Phone: 605-791-5959
  • Fax: 605-791-5960
Mailing address:
  • Phone: 605-791-5959
  • Fax: 605-791-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCP000223
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6702252
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: