Healthcare Provider Details

I. General information

NPI: 1013918036
Provider Name (Legal Business Name): JENNIFER ODDLEIFSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 WEST MAIN ST.-
WALDOBORO ME
04572-6030
US

IV. Provider business mailing address

PO BOX 745
NEWCASTLE ME
04553-0745
US

V. Phone/Fax

Practice location:
  • Phone: 207-832-6394
  • Fax: 207-832-4392
Mailing address:
  • Phone: 207-563-4511
  • Fax: 207-563-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA - 289
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA289
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: