Provider Demographics
NPI:1053621987
Name:CAMMACK, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CAMMACK
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 1:416 SPRINGY POND RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:ME
Mailing Address - Zip Code:04428-6175
Mailing Address - Country:US
Mailing Address - Phone:207-537-3369
Mailing Address - Fax:
Practice Address - Street 1:16 KIDS PEACE WAY
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-3483
Practice Address - Country:US
Practice Address - Phone:207-667-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1041225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist