Provider Demographics
NPI:1457489742
Name:JUBULIS, JENNIFER KLOTZ (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KLOTZ
Last Name:JUBULIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KLOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:301C US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 320
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-5522
Practice Address - Fax:207-662-5527
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0068961208000000X
MEMD19415208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD332504100Medicaid