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General NPI Number Information
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NPI Number | 1194136010
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Entity Type | Individual
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Provider Name | LUKE JARVIS JACKSON CRNA
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Gender | Male
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 1400 29TH ST S
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City | GREAT FALLS
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State | MT
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Zip | 59405-5353
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Country | US
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Telephone | 409-454-2171
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Fax |
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Provider Business Mailing Address
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Address Line | 543 W 2700 N
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City | NEPHI
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State | UT
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Zip | 84648-3004
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Country | US
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Telephone | 435-531-9643
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | NUR-RN-LIC-74240
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License Number State | MT
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