Provider Demographics
NPI:1407901473
Name:JANSEN, JODY (LCSW)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:JANSEN
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 1:370 RICHARDS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5276
Mailing Address - Country:US
Mailing Address - Phone:207-251-9118
Mailing Address - Fax:
Practice Address - Street 1:62 PORTLAND RD
Practice Address - Street 2:POST ROAD CENTER SUITE 6
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6658
Practice Address - Country:US
Practice Address - Phone:207-251-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC#56331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME00364402Medicare PIN