Healthcare Provider Details

I. General information

NPI: 1750285110
Provider Name (Legal Business Name): ISABELLE JACKSON LCPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

IV. Provider business mailing address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-6100
  • Fax:
Mailing address:
  • Phone: 207-973-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL9031
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: