MEDICARE: MR. CECIL TIMOTHY JACKSON CRNA

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	367500000X	Certified Registered Nurse Anesthetist	29774	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29774	OTHER	MT	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1851330666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CECIL TIMOTHY JACKSON CRNA

Provider Business Mailing Address
First Line	:	203 S DAISY ST
Second Line	:
City	:	SALMON
State	:	ID
Zip	:	83467-4709
Country	:	US
Telephone Number	:	208-756-2429
Fax Number	:	208-756-2429

Provider Business Practice Location Address
First Line	:	90 HIGHWAY 91 SOUTH
Second Line	:	C/O BARRETT HOSPITAL & HEALTHCARE
City	:	DILLON
State	:	MT
Zip	:	59725-3597
Country	:	US
Telephone Number	:	406-683-3000
Fax Number	:	406-683-3011

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	10/13/2016

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1326042078 — BARRETT HOSPITAL DEVELOPMENT CORPORATION
Practice Location Address:

600 MT HWY 91 SOUTH
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1366461303 — BARRETT HOSPITAL DEVELOPMENT CORPORATION
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