Provider Demographics
NPI:1194944868
Name:GILLEN, JERAD PAUL
Entity type:Individual
Prefix:
First Name:JERAD
Middle Name:PAUL
Last Name:GILLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 OAK DR
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-5433
Mailing Address - Country:US
Mailing Address - Phone:406-265-3448
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 664
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-9797
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-5941
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist