Basic Information
Provider Information | |||||||||
NPI: | 1235491390 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHRISTENSEN | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MCMSC, PA-C, ATC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RADEN | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MCMSC, PA-C, ATC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 200 COMMONS WAY | ||||||||
Address2: | SUITE B | ||||||||
City: | KALISPELL | ||||||||
State: | MT | ||||||||
PostalCode: | 599011915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067525170 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 COMMONS WAY STE B | ||||||||
Address2: |   | ||||||||
City: | KALISPELL | ||||||||
State: | MT | ||||||||
PostalCode: | 599011915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067525170 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2012 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 112ATR | MT | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | MED-PAC-LIC-44827 | MT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.