Provider Demographics
NPI:1972936227
Name:FAUQUE, JEFF JOSEPH (LAC)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:JOSEPH
Last Name:FAUQUE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-1514
Mailing Address - Country:US
Mailing Address - Phone:406-727-8892
Mailing Address - Fax:406-727-8172
Practice Address - Street 1:920 4TH AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-1514
Practice Address - Country:US
Practice Address - Phone:406-727-8892
Practice Address - Fax:406-727-8172
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT810410694101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)