Provider Demographics
NPI:1215784905
Name:BUSH, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N OREGON ST # 3624
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-3624
Mailing Address - Country:US
Mailing Address - Phone:270-576-2507
Mailing Address - Fax:
Practice Address - Street 1:200 N OREGON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3624
Practice Address - Country:US
Practice Address - Phone:270-576-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-12283235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty