Healthcare Provider Details

I. General information

NPI: 1306624374
Provider Name (Legal Business Name): JACOB ELIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS AVE # 208
LEWISTON ME
04240-6040
US

IV. Provider business mailing address

111 BACK COVE DR
TURNER ME
04282-3836
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8974
  • Fax:
Mailing address:
  • Phone: 207-577-8765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP231382
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: