Provider Demographics
NPI:1164766200
Name:KELLEY-YOUNG, JENNIFER (LADC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KELLEY-YOUNG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BAXTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1801
Mailing Address - Country:US
Mailing Address - Phone:207-775-5671
Mailing Address - Fax:207-871-1243
Practice Address - Street 1:11 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1801
Practice Address - Country:US
Practice Address - Phone:207-775-5671
Practice Address - Fax:207-871-1243
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)