Provider Demographics
NPI:1316933963
Name:CALDWELL, JENIFER DARLENE (PA C)
Entity type:Individual
Prefix:MRS
First Name:JENIFER
Middle Name:DARLENE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:JENIFER
Other - Middle Name:DARLENE
Other - Last Name:VAN DE POL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1224 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3041
Mailing Address - Country:US
Mailing Address - Phone:406-241-3357
Mailing Address - Fax:
Practice Address - Street 1:1224 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3041
Practice Address - Country:US
Practice Address - Phone:406-241-3357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA38508OtherWELLMARK BCBS
IA38508OtherWELLMARK BCBS
Q37729Medicare UPIN