Provider Demographics
NPI:1073139465
Name:FORAKER, JACLYN KIMBERLY (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:KIMBERLY
Last Name:FORAKER
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Gender:F
Credentials:FNP-C
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Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8941
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3979
Practice Address - Country:US
Practice Address - Phone:207-907-1155
Practice Address - Fax:207-907-1888
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2022-02-21
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Provider Licenses
StateLicense IDTaxonomies
MECNP201144363LF0000X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health