Provider Demographics
NPI:1700080579
Name:DODGE, JACQUELYN CONWAY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:CONWAY
Last Name:DODGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 BAYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:ME
Mailing Address - Zip Code:04605-6513
Mailing Address - Country:US
Mailing Address - Phone:207-667-9278
Mailing Address - Fax:
Practice Address - Street 1:198 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1941
Practice Address - Country:US
Practice Address - Phone:207-667-9278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME17751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical