Provider Demographics
NPI:1255187720
Name:MCMAHON, JACQUELINE ROSE (CNM)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 SOUTH AVE W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6502
Mailing Address - Country:US
Mailing Address - Phone:301-288-1031
Mailing Address - Fax:
Practice Address - Street 1:2831 FORT MISSOULA RD STE 232
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7479
Practice Address - Country:US
Practice Address - Phone:406-523-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAPRN-246385367A00000X
NM65667163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTAPRN-246385OtherCNM