Provider Demographics
NPI:1689852402
Name:JACOBS, SHELLEY M (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:M
Last Name:JACOBS
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 1:20 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-7332
Mailing Address - Country:US
Mailing Address - Phone:207-899-9953
Mailing Address - Fax:
Practice Address - Street 1:114 MAINE ST
Practice Address - Street 2:MAINE ST. COUNSELING CENTER, SUITE #9
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2011
Practice Address - Country:US
Practice Address - Phone:207-899-9953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC113701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical