Provider Demographics
NPI:1134487093
Name:PERRY, JESSICA MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:PERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VA CTR
Mailing Address - Street 2:171
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6719
Mailing Address - Country:US
Mailing Address - Phone:207-624-1451
Mailing Address - Fax:207-947-1862
Practice Address - Street 1:1 VA CTR
Practice Address - Street 2:171
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6719
Practice Address - Country:US
Practice Address - Phone:207-624-1451
Practice Address - Fax:207-947-1862
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC117481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical