Provider Demographics
NPI:1912428343
Name:LAVE', JACKIE KAY (MSN, APRN)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:KAY
Last Name:LAVE'
Suffix:
Gender:
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3254 GRANGER AVE E APT B1
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-7060
Mailing Address - Country:US
Mailing Address - Phone:406-208-8617
Mailing Address - Fax:
Practice Address - Street 1:4435 E CHANDLER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7651
Practice Address - Country:US
Practice Address - Phone:917-634-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT72727163W00000X
MTNUR-APRN-LIC-127957363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner