Provider Demographics
NPI:1275570400
Name:TINGLEY PRINCE, JENNIFER M (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:TINGLEY PRINCE
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 1:29 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4909
Mailing Address - Country:US
Mailing Address - Phone:207-942-3816
Mailing Address - Fax:207-561-4725
Practice Address - Street 1:62 ELM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3091
Practice Address - Country:US
Practice Address - Phone:207-553-7056
Practice Address - Fax:207-773-2082
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC10171104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098304OtherANTHEM LEGACY NUMBER
ME431515399Medicaid
ME431515399Medicaid