Provider Demographics
NPI:1841713633
Name:KOLE, JENNIFER ALICE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ALICE
Last Name:KOLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3112
Mailing Address - Country:US
Mailing Address - Phone:207-773-8161
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1735208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPA1735OtherMAINE BOARD OF LICENSURE IN MEDICINE
1142971OtherNATIONAL COMMISSION ON CERTIFICATION FOR PAS (NCCPA)