Healthcare Provider Details

I. General information

NPI: 1750578092
Provider Name (Legal Business Name): CONSTANCE I JENKINS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 UNION ST
BANGOR ME
04401
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-945-5247
  • Fax: 207-990-1248
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-947-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR040922
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberAP081618
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: