Provider Demographics
NPI:1285242255
Name:BURNS, JACOB (MSW-CC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BURNS
Suffix:
Gender:M
Credentials:MSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2432
Mailing Address - Country:US
Mailing Address - Phone:207-423-8691
Mailing Address - Fax:207-494-8471
Practice Address - Street 1:281 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2412
Practice Address - Country:US
Practice Address - Phone:207-494-8010
Practice Address - Fax:207-494-8471
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC18602104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker