Provider Demographics
NPI:1225020480
Name:TIBBETTS, JEAN HENDERSON (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:HENDERSON
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 STATE ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6630
Mailing Address - Country:US
Mailing Address - Phone:207-947-1291
Mailing Address - Fax:207-947-9241
Practice Address - Street 1:417 STATE ST
Practice Address - Street 2:SUITE 230
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6630
Practice Address - Country:US
Practice Address - Phone:207-947-1291
Practice Address - Fax:207-947-9241
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME221710099Medicaid
B86423Medicare UPIN
ME221710099Medicaid