Healthcare Provider Details

I. General information

NPI: 1518711787
Provider Name (Legal Business Name): JEREMY MICHAEL DONNELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 KINGSLAND XING
ELLSWORTH ME
04605-2570
US

IV. Provider business mailing address

180 ACADEMY ST STE 3
PRESQUE ISLE ME
04769-3183
US

V. Phone/Fax

Practice location:
  • Phone: 207-667-6890
  • Fax:
Mailing address:
  • Phone: 207-554-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC25966
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: