Basic Information
| Provider Information | |||||||||
| NPI: | 1366689077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULKKINEN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10187 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122015187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077774111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 CAMPUS AVE | ||||||||
| Address2: | SUITES A & B | ||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042406040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077553434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2009 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC12474 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.