Provider Demographics
NPI:1316321656
Name:PAO, JESSICA SHAVON (LMSW-CC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHAVON
Last Name:PAO
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SHAVON
Other - Last Name:FRENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:12 WESTBROOK CMN
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2819
Practice Address - Country:US
Practice Address - Phone:207-856-1500
Practice Address - Fax:207-856-1518
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC15488104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker