Provider Demographics
NPI:1316297187
Name:BURTON, JESSICA ROMANOFF (LCPC-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROMANOFF
Last Name:BURTON
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:BRITTING
Other - Last Name:ROMANOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67 SHAKER RD
Mailing Address - Street 2:#7
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-9640
Mailing Address - Country:US
Mailing Address - Phone:207-671-3553
Mailing Address - Fax:
Practice Address - Street 1:67 SHAKER RD
Practice Address - Street 2:#7
Practice Address - City:GRAY
Practice Address - State:ME
Practice Address - Zip Code:04039-9640
Practice Address - Country:US
Practice Address - Phone:207-671-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health