Healthcare Provider Details

I. General information

NPI: 1396858809
Provider Name (Legal Business Name): JEAN ANNE FELDEISEN LCSW, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 BRUNSWICK AVENUE SUITE 6
GARDINER ME
04345-2123
US

IV. Provider business mailing address

17 BRUNSWICK AVENUE SUITE 6
GARDINER ME
04345-2123
US

V. Phone/Fax

Practice location:
  • Phone: 207-588-0040
  • Fax: 207-588-0040
Mailing address:
  • Phone: 207-588-0040
  • Fax: 207-588-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC2249
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC8044
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLC8044
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: