Provider Demographics
NPI:1316442940
Name:HERSOM, JESSICA (LCSW, LADC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HERSOM
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FAWN CT
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2750
Mailing Address - Country:US
Mailing Address - Phone:207-570-8776
Mailing Address - Fax:
Practice Address - Street 1:119 NORTHPORT AVE FL 1
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6069
Practice Address - Country:US
Practice Address - Phone:207-570-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6782101YA0400X
CAC5848101YA0400X
LM16932104100000X
MELC201141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker