Basic Information
| Provider Information | |||||||||
| NPI: | 1801881180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | JAMIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4907 | ||||||||
| Address2: | 700 WEST KENT | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598064907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413277 | ||||||||
| FaxNumber: | 4065413950 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W KENT AVE | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598016772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065413277 | ||||||||
| FaxNumber: | 4065413950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 508 | MT | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 532792 | 05 | MT | MEDICAID | 565487 | 01 | ID | MEDICAID | OTHER |