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General NPI Number Information
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NPI Number | 1689980856
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Entity Type | Individual
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Provider Name | JANE ELLEN MACK SPL
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Gender | Female
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 284 CUMBERLAND AVE
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City | PORTLAND
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State | ME
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Zip | 04101-4927
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Country | US
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Telephone | 207-874-8250
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Fax |
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Provider Business Mailing Address
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Address Line | 49 BROAD COVE RD
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City | CAPE ELIZABETH
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State | ME
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Zip | 04107-2901
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Country | US
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Telephone | 207-799-6377
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 05
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License Number State | ME
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