Basic Information
| Provider Information | |||||||||
| NPI: | 1144800087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOSSEY | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARDY | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 ACADEMY ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075542352 | ||||||||
| FaxNumber: | 2075542351 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 MILL ST | ||||||||
| Address2: | |||||||||
| City: | HOULTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047301877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075326523 | ||||||||
| FaxNumber: | 2075323873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2021 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CAC7399 | ME | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.