Provider Demographics
NPI:1922612431
Name:WICKMAN, JAALA M (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JAALA
Middle Name:M
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:FNP-BC
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 1098
Mailing Address - Street 2:
Mailing Address - City:FRENCHTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59834-1098
Mailing Address - Country:US
Mailing Address - Phone:406-546-3631
Mailing Address - Fax:
Practice Address - Street 1:2827 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7408
Practice Address - Country:US
Practice Address - Phone:406-728-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT165714363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily