Provider Demographics
NPI:1902054968
Name:HAVERKAMP, JENNIFER L (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:HAVERKAMP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4808
Mailing Address - Country:US
Mailing Address - Phone:207-854-1801
Mailing Address - Fax:207-854-0260
Practice Address - Street 1:151 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4808
Practice Address - Country:US
Practice Address - Phone:207-854-1801
Practice Address - Fax:207-854-0260
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433071299Medicaid
ME000884501Medicare PIN