Provider Demographics
NPI:1447696489
Name:JENNER, AMY L (MAC DIPL AC LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:JENNER
Suffix:
Gender:F
Credentials:MAC DIPL AC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-5924
Mailing Address - Country:US
Mailing Address - Phone:207-542-1575
Mailing Address - Fax:
Practice Address - Street 1:91 ELM ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843-1906
Practice Address - Country:US
Practice Address - Phone:207-542-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC397171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist