Provider Demographics
NPI:1053473397
Name:JIMMERSON, GARY EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWARD
Last Name:JIMMERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442-1477
Mailing Address - Country:US
Mailing Address - Phone:406-622-5598
Mailing Address - Fax:406-622-9090
Practice Address - Street 1:1309 FRONT ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442
Practice Address - Country:US
Practice Address - Phone:406-622-5598
Practice Address - Fax:406-622-9090
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
40110OtherGREAT FALLS BC INS
MT04007720OtherSTATE FUND WORKERS COMP
MT42360OtherFORT BENTON BC INS
MT000004237Medicare ID - Type UnspecifiedFORT BENTON
U09562Medicare UPIN
MT000004233Medicare ID - Type UnspecifiedGREAT FALLS