Healthcare Provider Details

I. General information

NPI: 1073139465
Provider Name (Legal Business Name): JACLYN KIMBERLY FORAKER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 02/21/2022
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BROADWAY
BANGOR ME
04401-3979
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-1155
  • Fax: 207-907-1888
Mailing address:
  • Phone: 207-777-8941
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP201144
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberCNP201144
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: