=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447836929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER RENEE WIEDERHOLD APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2021
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 NORTH 2ND ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-642-0546
-----------------------------------------------------
Fax | 406-743-6065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 254
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59639-0254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-642-0546
-----------------------------------------------------
Fax | 406-743-6065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NUR-APRN-LIC-174614
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------