Provider Demographics
NPI:1558078295
Name:DESROSIER, JASMIN
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:
Last Name:DESROSIER
Suffix:
Gender:F
Credentials:
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 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-728-6520
Mailing Address - Fax:406-329-2799
Practice Address - Street 1:500 W BROADWAY ST STE 310
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-728-6520
Practice Address - Fax:406-329-2799
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-198735363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner