Provider Demographics
NPI:1609563899
Name:JACKSON, TRENA (LADC)
Entity type:Individual
Prefix:
First Name:TRENA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 CENTRAL AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-4620
Mailing Address - Country:US
Mailing Address - Phone:207-713-3757
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:207-312-6863
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC8895101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)