Provider Demographics
NPI:1710578133
Name:WASHIGNTON, JACQUES LA CREE (BT)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:LA CREE
Last Name:WASHIGNTON
Suffix:
Gender:M
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 LT MOSS RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7222
Mailing Address - Country:US
Mailing Address - Phone:406-549-6413
Mailing Address - Fax:
Practice Address - Street 1:3335 LT MOSS RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7222
Practice Address - Country:US
Practice Address - Phone:406-549-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician