Healthcare Provider Details

I. General information

NPI: 1144492562
Provider Name (Legal Business Name): JENNIFER C WOOD LADC, LCSW, CCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINE ST
LEWISTON ME
04240-6309
US

IV. Provider business mailing address

300 PINE ST
LEWISTON ME
04240-6309
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-3399
  • Fax: 207-777-3391
Mailing address:
  • Phone: 207-777-3399
  • Fax: 207-777-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC2287
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC10560
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: