Basic Information
| Provider Information | |||||||||
| NPI: | 1437373313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLETIER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 899 RIVERSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711200 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 HILLCREST AVE | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043465131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075829206 | ||||||||
| FaxNumber: | 2075829652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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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 | 171W00000X | LS6727 | ME | N | Other Service Providers | Contractor | 101Y00000X | CC4825 | ME | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.