MEDICARE: JENNIFER L. DESJARDINS MHRT-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LC5168	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103850000	OTHER	ME	MAINECARE

General Provider Information

NPI Number	:	1215123682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L. DESJARDINS MHRT-C

Provider Business Mailing Address
First Line	:	175 STRIP RD
Second Line	:	PO BOX 314
City	:	FORT KENT
State	:	ME
Zip	:	04743-1552
Country	:	US
Telephone Number	:	207-436-7027
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 MARKET ST
Second Line	:
City	:	FORT KENT
State	:	ME
Zip	:	04743-1418
Country	:	US
Telephone Number	:	207-436-7027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	11/13/2012

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