Healthcare Provider Details

I. General information

NPI: 1194414698
Provider Name (Legal Business Name): AMITY JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PEARL ST STE 470
PORTLAND ME
04101-7122
US

IV. Provider business mailing address

75 PEARL ST STE 470
PORTLAND ME
04101-7122
US

V. Phone/Fax

Practice location:
  • Phone: 207-619-3356
  • Fax: 207-300-6085
Mailing address:
  • Phone: 207-619-3356
  • Fax: 207-300-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC22099
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: