Healthcare Provider Details

I. General information

NPI: 1720041221
Provider Name (Legal Business Name): JEANNE LEE SCHACKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MOODY ST
SACO ME
04072-1536
US

IV. Provider business mailing address

60 HARRIET ST
SOUTH PORTLAND ME
04106-2003
US

V. Phone/Fax

Practice location:
  • Phone: 207-294-4657
  • Fax: 207-294-4649
Mailing address:
  • Phone: 207-799-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC8183
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: