Provider Demographics
NPI:1780986315
Name:CROCKETT, JEREMY MATTHEW (CADC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MATTHEW
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6848
Mailing Address - Country:US
Mailing Address - Phone:207-990-2870
Mailing Address - Fax:
Practice Address - Street 1:629 MAIN ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6848
Practice Address - Country:US
Practice Address - Phone:207-990-2870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC4227101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)