Provider Demographics
NPI:1356316343
Name:CRAIG, JACKSON L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:L
Last Name:CRAIG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6230 MAIN STREET
Mailing Address - Street 2:P O BOX 1858
Mailing Address - City:COLSTRIP
Mailing Address - State:MT
Mailing Address - Zip Code:59323-1858
Mailing Address - Country:US
Mailing Address - Phone:406-748-3600
Mailing Address - Fax:406-748-3606
Practice Address - Street 1:6230 MAIN STREET
Practice Address - Street 2:
Practice Address - City:COLSTRIP
Practice Address - State:MT
Practice Address - Zip Code:59323-1858
Practice Address - Country:US
Practice Address - Phone:406-748-3600
Practice Address - Fax:406-748-3606
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT72363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0432302Medicaid
MT0432302Medicaid