Basic Information
| Provider Information | |||||||||
| NPI: | 1245863653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERKINS | ||||||||
| FirstName: | JERICCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STACKPOLE | ||||||||
| OtherFirstName: | JERICCA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | 2072944649 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | 2072944649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2020 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | XM5375 | ME | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.