Basic Information
Provider Information | |||||||||
NPI: | 1861678781 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'CONNOR | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP, RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 78 ATLANTIC PLACE | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076616654 | ||||||||
FaxNumber: | 2078427773 | ||||||||
Practice Location | |||||||||
Address1: | 12 WESTBROOK CMN | ||||||||
Address2: |   | ||||||||
City: | WESTBROOK | ||||||||
State: | ME | ||||||||
PostalCode: | 040922819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078561500 | ||||||||
FaxNumber: | 2078561518 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2008 | ||||||||
LastUpdateDate: | 12/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN55663 | ME | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | CNP101026 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.