Provider Demographics
NPI:1407957418
Name:STOCKWELL, JEFFERY D (NP)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:D
Last Name:STOCKWELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1943
Mailing Address - Country:US
Mailing Address - Phone:406-345-3314
Mailing Address - Fax:406-345-3324
Practice Address - Street 1:2615 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2590
Practice Address - Country:US
Practice Address - Phone:701-456-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25328363LF0000X
NDR27770363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT370061OtherBLUE CROSS/BLUE SHIELD MT
P00298214OtherMEDICARE RAIL ROAD
MT4307550Medicaid
370061OtherFEDERAL BLUE CROSS
ND19836Medicaid
MT4307550Medicaid
370061OtherFEDERAL BLUE CROSS