Provider Demographics
NPI:1720623861
Name:MCILVAIN, JODIE (PA)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:MCILVAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 12TH AVE N STE 160W
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7508
Mailing Address - Country:US
Mailing Address - Phone:406-237-8500
Mailing Address - Fax:406-237-8501
Practice Address - Street 1:2900 12TH AVE N STE 160W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7508
Practice Address - Country:US
Practice Address - Phone:406-237-8500
Practice Address - Fax:406-237-8501
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT79246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant