Provider Demographics
NPI:1659310142
Name:SMALL, JENNIFER (LADC, CCS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5943
Mailing Address - Country:US
Mailing Address - Phone:207-739-2644
Mailing Address - Fax:207-739-2467
Practice Address - Street 1:235 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5943
Practice Address - Country:US
Practice Address - Phone:207-739-2644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC2466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME417940099Medicaid