Healthcare Provider Details

I. General information

NPI: 1972498335
Provider Name (Legal Business Name): JESSICA KATHLEEN BALTHAZAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W LOMBARD ST
BALTIMORE MD
21201-1512
US

IV. Provider business mailing address

3900 FAIRFAX DR UNIT 1300
ARLINGTON VA
22203-1687
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-0501
  • Fax:
Mailing address:
  • Phone: 631-617-7371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001316237
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: