Provider Demographics
NPI:1316087554
Name:FORNBERG, JENNIFER MARGARET (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARGARET
Last Name:FORNBERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:CATAUMET
Mailing Address - State:MA
Mailing Address - Zip Code:02534-0743
Mailing Address - Country:US
Mailing Address - Phone:508-615-6592
Mailing Address - Fax:
Practice Address - Street 1:33 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2843
Practice Address - Country:US
Practice Address - Phone:508-615-6592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8216103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51510Medicare ID - Type Unspecified