Provider Demographics
NPI:1881709426
Name:BORKUM, JONATHAN M (PHD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:BORKUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BIG SKY LN
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4340
Mailing Address - Country:US
Mailing Address - Phone:207-872-5800
Mailing Address - Fax:207-872-5888
Practice Address - Street 1:2 BIG SKY LN
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4340
Practice Address - Country:US
Practice Address - Phone:207-872-5800
Practice Address - Fax:207-872-5888
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS991103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME295420099Medicaid
MM9086OtherGROUP # MEDICARE
ME295420099Medicaid
MM8420Medicare PIN