Provider Demographics
NPI:1497059638
Name:JIIVANA INTEGRATIVE HEALTH PLLC
Entity Type:Organization
Organization Name:JIIVANA INTEGRATIVE HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARX
Authorized Official - Suffix:
Authorized Official - Credentials:APN-C
Authorized Official - Phone:406-546-3043
Mailing Address - Street 1:825 W. KENT ST.
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6619
Mailing Address - Country:US
Mailing Address - Phone:406-546-3043
Mailing Address - Fax:
Practice Address - Street 1:825 W. KENT ST.
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6619
Practice Address - Country:US
Practice Address - Phone:406-546-3043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAPN22313261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care