Healthcare Provider Details

I. General information

NPI: 1902903321
Provider Name (Legal Business Name): REBECCA L WHITE PMHNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 S HWY 89 STE 201
JACKSON WY
83001-8508
US

IV. Provider business mailing address

PO BOX 722
TETON VILLAGE WY
83025-0722
US

V. Phone/Fax

Practice location:
  • Phone: 307-690-4521
  • Fax: 949-695-2562
Mailing address:
  • Phone: 307-690-4521
  • Fax: 949-695-2562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number100917
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-629A
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP-100917
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-5072
License Number StateHI
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number19355.0277
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: