Provider Demographics
NPI:1366424558
Name:KAUTZMAN, JESSIE LYN (MD)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYN
Last Name:KAUTZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W PENNSYLVANIA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-1999
Mailing Address - Country:US
Mailing Address - Phone:406-563-8500
Mailing Address - Fax:406-563-8694
Practice Address - Street 1:401 S ALABAMA ST STE 6A
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2358
Practice Address - Country:US
Practice Address - Phone:406-563-7239
Practice Address - Fax:406-782-2890
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10036207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1366424558OtherNPI
H63764Medicare UPIN