Provider Demographics
NPI:1972395515
Name:MCCANNELL, JESSICA LYNN HART
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN HART
Last Name:MCCANNELL
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 SYLVAN RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4221
Mailing Address - Country:US
Mailing Address - Phone:207-401-4324
Mailing Address - Fax:207-401-4325
Practice Address - Street 1:82 SYLVAN RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4221
Practice Address - Country:US
Practice Address - Phone:207-401-4324
Practice Address - Fax:207-401-4325
Is Sole Proprietor?:No
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT7147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist