Healthcare Provider Details

I. General information

NPI: 1851331482
Provider Name (Legal Business Name): JESSICA ADRIANCE COWAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PINE ST
FREEPORT ME
04032-6213
US

IV. Provider business mailing address

30 PINE ST
FREEPORT ME
04032-6213
US

V. Phone/Fax

Practice location:
  • Phone: 707-272-2172
  • Fax:
Mailing address:
  • Phone: 707-272-2172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW26433
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19608
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: