1215123682 NPI number — JENNIFER L. DESJARDINS MHRT-C

Table of content: JENNIFER L. DESJARDINS MHRT-C (NPI 1215123682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215123682 NPI number — JENNIFER L. DESJARDINS MHRT-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESJARDINS
Provider First Name:
JENNIFER
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MHRT-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DESJARDINS
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LADC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1215123682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 STRIP RD
Provider Second Line Business Mailing Address:
PO BOX 314
Provider Business Mailing Address City Name:
FORT KENT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04743-1552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-436-7027
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT KENT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04743-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-436-7027
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LC5168 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103850000 . This is a "MAINECARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".