Provider Demographics
NPI:1063532653
Name:BROGAN, JENNINE C (APRN)
Entity type:Individual
Prefix:
First Name:JENNINE
Middle Name:C
Last Name:BROGAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNINE
Other - Middle Name:C
Other - Last Name:VALCORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1200 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1103 WESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2342
Practice Address - Country:US
Practice Address - Phone:406-375-4119
Practice Address - Fax:406-541-2140
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-100801363L00000X
CA495954363L00000X
WANP60145148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT100006475Medicaid
ID1063532653Medicaid
CAGR0079700Medicaid
MT1063532653Medicaid
CAZZZ13858ZOtherMEDICARE GRP #
MTM011003948Medicare Oscar/Certification