Provider Demographics
NPI:1821890872
Name:SPOTTED BULL, JESSICA ROSE (LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:SPOTTED BULL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1098
Mailing Address - Street 2:
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255-1098
Mailing Address - Country:US
Mailing Address - Phone:406-561-7872
Mailing Address - Fax:
Practice Address - Street 1:417 EAST 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255
Practice Address - Country:US
Practice Address - Phone:406-768-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-78972101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)