Provider Demographics
NPI:1760731707
Name:WATSON, JANE TULL (LMSW-CC, CADC)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:TULL
Last Name:WATSON
Suffix:
Gender:F
Credentials:LMSW-CC, CADC
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:ANN
Other - Last Name:TULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-871-1211
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:477 CONGRESS ST
Practice Address - Street 2:SUITE 408
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3427
Practice Address - Country:US
Practice Address - Phone:207-773-7811
Practice Address - Fax:207-773-0663
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5226101YA0400X
MEMC136891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)