Provider Demographics
NPI:1801224209
Name:MOEN, JACQUELINE LYNN (NP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LYNN
Last Name:MOEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 RISING SUN LN
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:MT
Mailing Address - Zip Code:59421-8025
Mailing Address - Country:US
Mailing Address - Phone:406-390-5637
Mailing Address - Fax:
Practice Address - Street 1:300 GARNET WAY
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:MT
Practice Address - Zip Code:59756
Practice Address - Country:US
Practice Address - Phone:406-693-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT29160363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health