Healthcare Provider Details

I. General information

NPI: 1457489742
Provider Name (Legal Business Name): JENNIFER KLOTZ JUBULIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER KLOTZ MD

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST SUITE 320
PORTLAND ME
04102
US

IV. Provider business mailing address

301C US ROUTE ONE
SCARBOROUGH ME
04074
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5522
  • Fax: 207-662-5527
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0068961
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD19415
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberMD19415
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: