Provider Demographics
NPI:1780729954
Name:EILTS-MCKENNEY, JENNIFER LEE (NP, RN, LCPC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:EILTS-MCKENNEY
Suffix:
Gender:F
Credentials:NP, RN, LCPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:EILTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:165 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2410101YP2500X
MECNP141074363LP0808X
MERN59388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400172593Medicare PIN