Provider Demographics
NPI:1871370197
Name:ROGERS, JEFFREY RICHARD (BBH-ACLC-LIC 64043)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
Last Name:ROGERS
Suffix:
Gender:M
Credentials:BBH-ACLC-LIC 64043
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 SW HIGGINS AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1423
Mailing Address - Country:US
Mailing Address - Phone:406-540-4120
Mailing Address - Fax:
Practice Address - Street 1:913 SW HIGGINS AVE STE 201
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1423
Practice Address - Country:US
Practice Address - Phone:406-540-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-64043101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)