Healthcare Provider Details

I. General information

NPI: 1609877018
Provider Name (Legal Business Name): PATRICIA POLK JETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 LUBRANO DR SUITE 100
ANNAPOLIS MD
21401-7566
US

IV. Provider business mailing address

1111 BENFIELD BLVD SUITE 200
MILLERSVILLE MD
21108-3002
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-5852
  • Fax: 410-266-5095
Mailing address:
  • Phone: 410-729-5100
  • Fax: 410-729-5156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD50756
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: