Healthcare Provider Details

I. General information

NPI: 1821890872
Provider Name (Legal Business Name): JESSICA ROSE SPOTTED BULL LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 03/27/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 EAST 13TH AVENUE
POPLAR MT
59255
US

IV. Provider business mailing address

PO BOX 1098
POPLAR MT
59255-1098
US

V. Phone/Fax

Practice location:
  • Phone: 406-768-3052
  • Fax:
Mailing address:
  • Phone: 406-561-7872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBBH-LAC-LIC-78972
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: