Provider Demographics
NPI:1720513476
Name:POULIN, JESSICA LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:POULIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:LAVIOLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:180 KENNEDY MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4540
Mailing Address - Country:US
Mailing Address - Phone:207-861-7050
Mailing Address - Fax:
Practice Address - Street 1:180 KENNEDY MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4540
Practice Address - Country:US
Practice Address - Phone:207-861-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO3061204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM