Provider Demographics
NPI:1275360760
Name:EASTTEY, JILLIAN KIMBERLY (LMSW-CC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:KIMBERLY
Last Name:EASTTEY
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 JOHN ROBERTS RD STE B8
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6964
Mailing Address - Country:US
Mailing Address - Phone:207-775-4151
Mailing Address - Fax:
Practice Address - Street 1:75 JOHN ROBERTS RD STE B8
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6964
Practice Address - Country:US
Practice Address - Phone:207-775-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC240111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical