Healthcare Provider Details

I. General information

NPI: 1902405582
Provider Name (Legal Business Name): JENNIFER LEIGH REARDON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 BATH RD
BRUNSWICK ME
04011-2607
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 207-424-2272
  • Fax: 207-424-2268
Mailing address:
  • Phone: 603-410-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP241693
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number200441874
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number60699055
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10000620
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: