Provider Demographics
NPI:1679741839
Name:JENNINGS, MARY KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:JENNINGS
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 1:100 FODEN RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2327
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 1000
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1392
Practice Address - Country:US
Practice Address - Phone:207-774-4092
Practice Address - Fax:207-523-8596
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME016582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209656Medicaid
ME001740201Medicare PIN
H47749Medicare UPIN