Provider Demographics
NPI:1154468130
Name:DAVIS, JENNI E (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:JENNI
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:JENNI
Other - Middle Name:E
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:165 LANCASTER STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC124181041C0700X
MECAC4311101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400285812Medicare PIN