Provider Demographics
NPI:1962599720
Name:NICOLETTE, JODEAN (MD)
Entity type:Individual
Prefix:
First Name:JODEAN
Middle Name:
Last Name:NICOLETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 RAILROAD ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4109
Mailing Address - Country:US
Mailing Address - Phone:406-258-4789
Mailing Address - Fax:406-258-4732
Practice Address - Street 1:45280 SEELEY DR
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-6834
Practice Address - Country:US
Practice Address - Phone:760-834-7920
Practice Address - Fax:760-834-7921
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66309207Q00000X
MT68166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A663090Medicaid
CA00A663090Medicare ID - Type Unspecified
CAH31720Medicare UPIN