Basic Information
| Provider Information | |||||||||
| NPI: | 1285686568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUEGER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 WESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063754823 | ||||||||
| FaxNumber: | 4063754846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 WESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063635101 | ||||||||
| FaxNumber: | 4063637652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 57 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 4303689 | 05 | MT | MEDICAID | 1285686568 | 05 | ID | MEDICAID |