Provider Demographics
NPI:1457150484
Name:FANGSRUD, JAMIE MARIE (PCLC)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:MARIE
Last Name:FANGSRUD
Suffix:
Gender:
Credentials:PCLC
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:MARIE
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:143 ERICKSON CT N
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-2346
Mailing Address - Country:US
Mailing Address - Phone:406-672-1352
Mailing Address - Fax:
Practice Address - Street 1:919 BROADWATER SQ
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1634
Practice Address - Country:US
Practice Address - Phone:406-970-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-APP-78450101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor