Provider Demographics
NPI:1386710366
Name:NELSON, JERRIE LYNN (LICAC)
Entity type:Individual
Prefix:
First Name:JERRIE
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9340 S FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-6100
Mailing Address - Country:US
Mailing Address - Phone:406-656-7416
Mailing Address - Fax:406-294-0967
Practice Address - Street 1:9340 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-6100
Practice Address - Country:US
Practice Address - Phone:406-656-7416
Practice Address - Fax:406-294-0967
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT142133N00000X
MT123171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0089138OtherBCBS