Provider Demographics
NPI:1720471378
Name:POULIN, JACQUELYN (LCPC, ATR)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:
Last Name:POULIN
Suffix:
Gender:F
Credentials:LCPC, ATR
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:RAYMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 NORTHERN RD
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769
Mailing Address - Country:US
Mailing Address - Phone:207-764-7219
Mailing Address - Fax:
Practice Address - Street 1:8 NORTHERN RD
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769
Practice Address - Country:US
Practice Address - Phone:207-764-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4381101YM0800X
ME17-064221700000X
MECC5072101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist