Healthcare Provider Details

I. General information

NPI: 1619708385
Provider Name (Legal Business Name): ANGELA JACOBS HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 MAPLE ST STE D
CORNISH ME
04020-3149
US

IV. Provider business mailing address

944 ROOSEVELT TRL STE 12
WINDHAM ME
04062-5699
US

V. Phone/Fax

Practice location:
  • Phone: 207-893-2930
  • Fax:
Mailing address:
  • Phone: 207-893-2930
  • Fax: 207-893-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberDL470
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: