Provider Demographics
NPI:1669732152
Name:JACQUES, BETHANIE (LCPC)
Entity type:Individual
Prefix:
First Name:BETHANIE
Middle Name:
Last Name:JACQUES
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04098-0150
Mailing Address - Country:US
Mailing Address - Phone:207-879-6165
Mailing Address - Fax:207-879-7466
Practice Address - Street 1:741 WARREN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1007
Practice Address - Country:US
Practice Address - Phone:207-879-6165
Practice Address - Fax:207-879-7466
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3960101YP2500X
MECC4878101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional