Provider Demographics
NPI:1144766734
Name:GRUNDSTROM-WHITNEY, JASON (LADC/LSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GRUNDSTROM-WHITNEY
Suffix:
Gender:M
Credentials:LADC/LSW
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:SCOTT
Other - Last Name:GRUNDSTROM-WHITENY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LADC/LSW
Mailing Address - Street 1:37 MIKES RD
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04259-7226
Mailing Address - Country:US
Mailing Address - Phone:207-624-3999
Mailing Address - Fax:
Practice Address - Street 1:250 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5742
Practice Address - Country:US
Practice Address - Phone:207-624-3999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3358101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)