Healthcare Provider Details

I. General information

NPI: 1033398680
Provider Name (Legal Business Name): THE JASON PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 WASHINGTON AVE
PORTLAND ME
04101-2617
US

IV. Provider business mailing address

65 WASHINGTON AVE
PORTLAND ME
04101-2617
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-2947
  • Fax: 207-773-3617
Mailing address:
  • Phone: 207-773-2947
  • Fax: 207-773-3617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number012046
License Number StateME

VIII. Authorized Official

Name: MRS. DIANA H HURD
Title or Position: PRACTICE MANAGER
Credential:
Phone: 207-773-2947