Provider Demographics
NPI:1477969541
Name:JEFFERSON, GRETCHEN (PHD, BCBA-D, NCSP)
Entity Type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PHD, BCBA-D, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CRESCENT ST # 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3114
Mailing Address - Country:US
Mailing Address - Phone:207-232-7443
Mailing Address - Fax:
Practice Address - Street 1:15 SAUNDERS WAY WOODFORDS FAMILY SERVICES
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092
Practice Address - Country:US
Practice Address - Phone:207-232-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1-04-1922103K00000X
ME31656103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool