Provider Demographics
NPI:1972900652
Name:JANDREAU, STEPHANIE (MHRT-CSP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JANDREAU
Suffix:
Gender:F
Credentials:MHRT-CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1407
Mailing Address - Country:US
Mailing Address - Phone:207-834-3186
Mailing Address - Fax:207-834-7190
Practice Address - Street 1:104 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743
Practice Address - Country:US
Practice Address - Phone:207-834-3186
Practice Address - Fax:207-834-7190
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1972900652Medicaid