Provider Demographics
NPI:1215123682
Name:DESJARDINS, JENNIFER L (MHRT-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DESJARDINS
Suffix:
Gender:F
Credentials:MHRT-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:DESJARDINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LADC
Mailing Address - Street 1:175 STRIP RD
Mailing Address - Street 2:PO BOX 314
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1552
Mailing Address - Country:US
Mailing Address - Phone:207-436-7027
Mailing Address - Fax:
Practice Address - Street 1:31 MARKET ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1418
Practice Address - Country:US
Practice Address - Phone:207-436-7027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC5168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103850000OtherMAINECARE