Healthcare Provider Details

I. General information

NPI: 1225012586
Provider Name (Legal Business Name): JENNIFER ANN CIVITELLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNY MCCALLEN MD

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 ELM ST
ANTRIM NH
03440-3916
US

IV. Provider business mailing address

12 ELM ST
ANTRIM NH
03440-3916
US

V. Phone/Fax

Practice location:
  • Phone: 603-588-4200
  • Fax: 603-588-4089
Mailing address:
  • Phone: 603-588-4200
  • Fax: 603-588-4089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12233
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: