1225717150 NPI number — JENNIFER PRETTYBULL SWLC

Table of content: JENNIFER PRETTYBULL SWLC (NPI 1225717150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225717150 NPI number — JENNIFER PRETTYBULL SWLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRETTYBULL
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SWLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRETTYBULL
Provider Other First Name:
JP
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SWLC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1225717150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1183
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POLSON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59860-1183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-860-8904
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
63 BOGEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POLSON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59860-9656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-860-8904
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  BBH-SWLC-LIC-62383 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)