Provider Demographics
NPI:1477324671
Name:MCCLEARY, JACQUELYN ROSE
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:MCCLEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 LAKERS WAY APT 4
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-8556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 RIDGEWATER DR STE A
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-8977
Practice Address - Country:US
Practice Address - Phone:406-883-3200
Practice Address - Fax:406-883-9483
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-145547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant