Provider Demographics
NPI:1588680177
Name:JANDREAU, STACY-JO W (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY-JO
Middle Name:W
Last Name:JANDREAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3102
Mailing Address - Country:US
Mailing Address - Phone:207-768-4100
Mailing Address - Fax:207-768-4014
Practice Address - Street 1:140 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-768-4100
Practice Address - Fax:207-768-4014
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14812207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1588680177Medicaid
ME1588680177Medicaid