Provider Demographics
NPI:1982750659
Name:JERNIGAN, EDWARD B JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:JERNIGAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4312
Practice Address - Country:US
Practice Address - Phone:207-275-4290
Practice Address - Fax:207-973-7674
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM107652084N0402X
MEMD209132084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology