Provider Demographics
NPI:1285809921
Name:HART, JODIE LYNN (LADC)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:LYNN
Last Name:HART
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:LYNN
Other - Last Name:JACQUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04332-0558
Mailing Address - Country:US
Mailing Address - Phone:207-626-3448
Mailing Address - Fax:207-621-6228
Practice Address - Street 1:10 CALDWELL RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5735
Practice Address - Country:US
Practice Address - Phone:207-626-3448
Practice Address - Fax:207-626-3448
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC3990101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432887699Medicaid