Healthcare Provider Details

I. General information

NPI: 1942310255
Provider Name (Legal Business Name): DIANE JAECKEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 ANDOVER RD
WESTBROOK ME
04092-3848
US

IV. Provider business mailing address

123 ANDOVER RD
WESTBROOK ME
04092-3848
US

V. Phone/Fax

Practice location:
  • Phone: 207-761-2200
  • Fax: 207-842-7773
Mailing address:
  • Phone: 207-761-2200
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLI714
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: