Provider Demographics
NPI:1700834736
Name:FREEDMAN, JONATHAN MACK (PH D)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MACK
Last Name:FREEDMAN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MANNING MILL RD
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-1021
Mailing Address - Country:US
Mailing Address - Phone:207-498-6395
Mailing Address - Fax:855-654-1335
Practice Address - Street 1:15 CROSS ST STE 20
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6356
Practice Address - Country:US
Practice Address - Phone:207-498-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME490103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM0742Medicare ID - Type UnspecifiedMEDICARE ID