1104603604 NPI number — JILLIAN MARY BEAL INGERSON LMT

Table of content: JILLIAN MARY BEAL INGERSON LMT (NPI 1104603604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104603604 NPI number — JILLIAN MARY BEAL INGERSON LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGERSON
Provider First Name:
JILLIAN
Provider Middle Name:
MARY BEAL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEAL
Provider Other First Name:
JILLIAN
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104603604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04489-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-992-4000
Provider Business Mailing Address Fax Number:
207-558-3285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 PERRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-6722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-992-4000
Provider Business Practice Location Address Fax Number:
207-558-3285
Provider Enumeration Date:
09/11/2023

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: 225700000X , with the licence number:  MT4637 , 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)





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