=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982002564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI JANDREAU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2014
-----------------------------------------------------
Last Update Date | 01/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 MAIN ST UNIT T-2
-----------------------------------------------------
City | NEWPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04953-4156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-924-0077
-----------------------------------------------------
Fax | 207-924-0078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 KENMOOR AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-356-5000
-----------------------------------------------------
Fax | 616-356-5001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT5002
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------