Provider Demographics
NPI:1902612237
Name:HERBERT, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HERBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 HOGAN RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3626
Mailing Address - Country:US
Mailing Address - Phone:207-973-0400
Mailing Address - Fax:207-973-1881
Practice Address - Street 1:362 CENTER ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1658
Practice Address - Country:US
Practice Address - Phone:207-631-0186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC8820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)