Provider Demographics
NPI:1588901706
Name:ANTKIES, JASON ROSS (LADC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ROSS
Last Name:ANTKIES
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7030
Mailing Address - Country:US
Mailing Address - Phone:207-782-3386
Mailing Address - Fax:
Practice Address - Street 1:369 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7030
Practice Address - Country:US
Practice Address - Phone:207-782-3386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC5263101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)