Provider Demographics
NPI:1750476586
Name:JETTINGHOFF, KIRSTEN LOUISE (LCPC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LOUISE
Last Name:JETTINGHOFF
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-4043
Mailing Address - Country:US
Mailing Address - Phone:207-671-4325
Mailing Address - Fax:
Practice Address - Street 1:100 GRAY RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-2018
Practice Address - Country:US
Practice Address - Phone:207-671-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2729101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431730699Medicaid