Basic Information
| Provider Information | |||||||||
| NPI: | 1609022474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MSN, GNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 KENNEDY MEMORIAL DR | ||||||||
| Address2: | STE 202 EVERGEREEN FAMILY PRACTICE | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736655 | ||||||||
| FaxNumber: | 2078779826 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 KENNEDY MEMORIAL DR | ||||||||
| Address2: | STE 202 EVERGEREEN FAMILY PRACTICE | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736655 | ||||||||
| FaxNumber: | 2078779826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R054879 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | R054879 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 433129799 | 05 | ME | MEDICAID |