=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457150484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMIE MARIE FANGSRUD PCLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 BROADWATER SQ
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59101-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-970-9770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 143 ERICKSON CT N
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59105-2346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-672-1352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | BBH-PCLC-APP-78450
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------