Healthcare Provider Details

I. General information

NPI: 1992937130
Provider Name (Legal Business Name): CHRISTOPHER OWEN JENNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VA CTR VAMC- TOGUS
AUGUSTA ME
04330-6719
US

IV. Provider business mailing address

150 METCALF RD
WINTHROP ME
04364-3375
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax:
Mailing address:
  • Phone: 207-377-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP091044
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: