MEDICARE: DR. WANMDIWI JESSI ROSE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY60720535	WA
2	103T00000X	Psychologist	PSY-PSY-LIC-2506	MT

General Provider Information

NPI Number	:	1730687518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WANMDIWI JESSI ROSE PH.D.

Provider Business Mailing Address
First Line	:	300 POPLAR LN
Second Line	:
City	:	FLORENCE
State	:	MT
Zip	:	59833-6834
Country	:	US
Telephone Number	:	713-494-3341
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 CENTRAL AVE STE 311
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59401-3157
Country	:	US
Telephone Number	:	406-866-0013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2018
Last Update Date	:	12/01/2021

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