Basic Information
| Provider Information | |||||||||
| NPI: | 1720321649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMMERS-SHEA | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEA | ||||||||
| OtherFirstName: | JENNIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 WASHINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041032842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711200 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 WASHINGTON AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041032842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078711200 | ||||||||
| FaxNumber: | 2078711232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC4621 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.