Healthcare Provider Details

I. General information

NPI: 1073859674
Provider Name (Legal Business Name): JENNY J WHITE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 FIELDSTONE XING
SOUTH CHINA ME
04358-5200
US

IV. Provider business mailing address

24 FIELDSTONE XING
SOUTH CHINA ME
04358-5200
US

V. Phone/Fax

Practice location:
  • Phone: 207-689-8003
  • Fax:
Mailing address:
  • Phone: 207-689-8003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number5006
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: