Healthcare Provider Details

I. General information

NPI: 1114841632
Provider Name (Legal Business Name): JENNY MARIE OMLOR LCPC-C, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 BENNOCH RD
OLD TOWN ME
04468-5508
US

IV. Provider business mailing address

776 BENNOCH RD
OLD TOWN ME
04468-5508
US

V. Phone/Fax

Practice location:
  • Phone: 207-279-9792
  • Fax:
Mailing address:
  • Phone: 207-279-9792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL6928
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: