Healthcare Provider Details

I. General information

NPI: 1720734098
Provider Name (Legal Business Name): JENNA LAKEMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 ODLIN RD
BANGOR ME
04401-6709
US

IV. Provider business mailing address

689 ODLIN RD
BANGOR ME
04401-6709
US

V. Phone/Fax

Practice location:
  • Phone: 207-694-1814
  • Fax:
Mailing address:
  • Phone: 207-694-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN74469
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: