Provider Demographics
NPI:1184852451
Name:EVERETT, JACE LEE (DOCTORATE)
Entity Type:Individual
Prefix:DR
First Name:JACE
Middle Name:LEE
Last Name:EVERETT
Suffix:
Gender:M
Credentials:DOCTORATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 11TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-5367
Mailing Address - Country:US
Mailing Address - Phone:406-488-7193
Mailing Address - Fax:
Practice Address - Street 1:216 14TH AVE SW
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-3519
Practice Address - Country:US
Practice Address - Phone:406-488-2166
Practice Address - Fax:406-488-2220
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist