Provider Demographics
NPI:1003867037
Name:ECKSTROM, JENNIE WALKER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:WALKER
Last Name:ECKSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:KAY
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 BAKER AVE
Mailing Address - Street 2:GLACIER MEDICAL ASSOCIATES
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2901
Mailing Address - Country:US
Mailing Address - Phone:406-862-2515
Mailing Address - Fax:406-862-4229
Practice Address - Street 1:1111 BAKER AVE
Practice Address - Street 2:GLACIER MEDICAL ASSOCIATES
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2901
Practice Address - Country:US
Practice Address - Phone:406-862-2515
Practice Address - Fax:406-862-4229
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9143207Q00000X
MT10784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT810350909OtherFEIN
MT27D0411341OtherCLIA ID#--LAB CERT
MTP00234037OtherRAILROAD MEDICARE PIN#
MT000008287OtherMEDICARE PART B GRP ID#
MTCI2709OtherRAILROAD MEDICARE GRP ID#
MT1104882232OtherGLACIER MEDICAL ASSOC NPI
MT000094766OtherBLUE CROSS/SHIELD PIN
MT0143442Medicaid
MT10784OtherMONTANA STATE LICENSE
IDRES000Medicare UPIN
MTP00234037OtherRAILROAD MEDICARE PIN#
MT810350909OtherFEIN
MTP00234037Medicare PIN