Provider Demographics
NPI:1013918036
Name:ODDLEIFSON, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ODDLEIFSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:ME
Mailing Address - Zip Code:04553-0745
Mailing Address - Country:US
Mailing Address - Phone:207-563-4511
Mailing Address - Fax:207-563-4103
Practice Address - Street 1:592 WEST MAIN ST.-
Practice Address - Street 2:
Practice Address - City:WALDOBORO
Practice Address - State:ME
Practice Address - Zip Code:04572-6030
Practice Address - Country:US
Practice Address - Phone:207-832-6394
Practice Address - Fax:207-832-4392
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA - 289363A00000X
MEPA289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME290260099Medicaid
S31605Medicare UPIN
ME290260099Medicaid