Provider Demographics
NPI:1992826192
Name:VERRILL, JESSICA A (MT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:VERRILL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 DINGLEY SPRING RD
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2169
Mailing Address - Country:US
Mailing Address - Phone:207-899-0222
Mailing Address - Fax:
Practice Address - Street 1:118 MAINE MALL RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2309
Practice Address - Country:US
Practice Address - Phone:207-899-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT2532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME099083OtherANTHEM
ME1992829162OtherAETNA