Healthcare Provider Details

I. General information

NPI: 1902054968
Provider Name (Legal Business Name): JENNIFER L HAVERKAMP OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MAIN ST
WESTBROOK ME
04092-4808
US

IV. Provider business mailing address

151 MAIN ST
WESTBROOK ME
04092-4808
US

V. Phone/Fax

Practice location:
  • Phone: 207-854-1801
  • Fax: 207-854-0260
Mailing address:
  • Phone: 207-854-1801
  • Fax: 207-854-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT902
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: