Provider Demographics
NPI:1033540687
Name:SMALL, JESSICA DEMERISE (LCPC-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DEMERISE
Last Name:SMALL
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6508
Mailing Address - Country:US
Mailing Address - Phone:207-941-6434
Mailing Address - Fax:207-941-9366
Practice Address - Street 1:202 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6508
Practice Address - Country:US
Practice Address - Phone:207-941-6434
Practice Address - Fax:207-941-9366
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4254101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health