Provider Demographics
NPI:1295183994
Name:DOTY, JENNIFER RAE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:DOTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W SPRUCE ST STE J
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4047
Mailing Address - Country:US
Mailing Address - Phone:406-329-4142
Mailing Address - Fax:
Practice Address - Street 1:601 W SPRUCE ST STE J
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4047
Practice Address - Country:US
Practice Address - Phone:406-327-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT60099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1295183994Medicaid