Provider Demographics
NPI:1770137358
Name:OUELLETTE, JENNIFER ANTHONY ROCHE (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANTHONY ROCHE
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANTHONY
Other - Last Name:ROCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 MAINE ST STE A423
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2098
Mailing Address - Country:US
Mailing Address - Phone:207-945-1700
Mailing Address - Fax:
Practice Address - Street 1:135 MAINE ST STE A423
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2098
Practice Address - Country:US
Practice Address - Phone:207-945-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC209081041C0700X
MEMC18087104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker