Provider Demographics
NPI:1891170809
Name:PARKS, JESSICA L (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:PARKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PLATANITIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:185 BUCK ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 SAUNDERS WAY
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092
Practice Address - Country:US
Practice Address - Phone:207-878-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC154891041C0700X
MELC167221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1366786410Medicaid
ME1417209826Medicaid