Provider Demographics
NPI:1902865397
Name:GREAVES, JENNIFER WARREN (LCSW, LADC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:WARREN
Last Name:GREAVES
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:WARREN
Other - Last Name:FOWLER-GREAVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, LADC
Mailing Address - Street 1:95 PARKER ST
Mailing Address - Street 2:STE 5
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-4034
Mailing Address - Country:US
Mailing Address - Phone:207-773-3300
Mailing Address - Fax:
Practice Address - Street 1:106 SKYLARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2082
Practice Address - Country:US
Practice Address - Phone:207-831-2580
Practice Address - Fax:207-221-2957
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1990101YA0400X
MELC29651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME079201OtherANTHEM
ME328620099Medicaid
MEGR-ME1620Medicare ID - Type Unspecified