Provider Demographics
NPI:1750026860
Name:JETT, PHOENIX R
Entity type:Individual
Prefix:
First Name:PHOENIX
Middle Name:R
Last Name:JETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:E
Other - Last Name:THERIAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC
Mailing Address - Street 1:18 MOLLISON WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5811
Mailing Address - Country:US
Mailing Address - Phone:207-312-6860
Mailing Address - Fax:
Practice Address - Street 1:18 MOLLISON WAY
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5811
Practice Address - Country:US
Practice Address - Phone:207-312-6860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC7863101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)