Provider Demographics
NPI:1407087505
Name:IRISH, JANE MARIE (LADC)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:MARIE
Last Name:IRISH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:MARIE
Other - Last Name:POOLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6397
Mailing Address - Country:US
Mailing Address - Phone:207-478-9613
Mailing Address - Fax:
Practice Address - Street 1:253-255 HAMMOND ST.
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-478-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4893101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434381199Medicaid