Provider Demographics
NPI:1992833669
Name:WATERMAN, JENNIFER (LCPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WATERMAN
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 1:96 INDIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4230
Mailing Address - Country:US
Mailing Address - Phone:207-772-2202
Mailing Address - Fax:
Practice Address - Street 1:96 INDIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4230
Practice Address - Country:US
Practice Address - Phone:207-772-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC25531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME417990099Medicaid