Healthcare Provider Details

I. General information

NPI: 1437373313
Provider Name (Legal Business Name): JENNIFER L PELLETIER LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HILLCREST AVE
RANDOLPH ME
04346-5131
US

IV. Provider business mailing address

899 RIVERSIDE ST
PORTLAND ME
04103-1070
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-9206
  • Fax: 207-582-9652
Mailing address:
  • Phone: 207-871-1200
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberLS6727
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCC4825
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: