Provider Demographics
NPI:1336250208
Name:JAHNKE, SCOTT RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RICHARD
Last Name:JAHNKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MERIDIAN CT STE 2
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4240
Mailing Address - Country:US
Mailing Address - Phone:406-755-4488
Mailing Address - Fax:
Practice Address - Street 1:3 MERIDIAN CT STE 2
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4240
Practice Address - Country:US
Practice Address - Phone:406-755-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT109472081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4976249-11Medicaid
MI554111654OtherBLUE CROSS BLUE SHIELD
MI554111654OtherBLUE CROSS BLUE SHIELD
F47688Medicare UPIN