Healthcare Provider Details

I. General information

NPI: 1306296090
Provider Name (Legal Business Name): JEANA COGGINS CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MAIN ST
BIDDEFORD ME
04005-2410
US

IV. Provider business mailing address

74 TEMPLE ST APT 1
SACO ME
04072-2742
US

V. Phone/Fax

Practice location:
  • Phone: 207-893-3086
  • Fax:
Mailing address:
  • Phone: 207-420-5880
  • Fax: 207-893-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC6027
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: