Provider Demographics
NPI:1861678781
Name:O'CONNOR, JENNIFER MARIE (NP, RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:12 WESTBROOK CMN
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2819
Practice Address - Country:US
Practice Address - Phone:207-856-1500
Practice Address - Fax:207-856-1518
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN55663163W00000X
MECNP101026363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001716601Medicare PIN
MEE400170381Medicare PIN