Provider Demographics
NPI:1316371461
Name:DIMICK, JACQUELINE DIANE (MED, LCPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:DIMICK
Suffix:
Gender:F
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DIANE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC-C
Mailing Address - Street 1:251 MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6754
Mailing Address - Country:US
Mailing Address - Phone:207-844-4997
Mailing Address - Fax:
Practice Address - Street 1:251 MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6754
Practice Address - Country:US
Practice Address - Phone:207-844-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4994101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional