Healthcare Provider Details

I. General information

NPI: 1194275008
Provider Name (Legal Business Name): JENNIFER POULIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/30/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 LIGHT STREET
BALTIMORE MD
21230
US

IV. Provider business mailing address

2804 GEORGETOWN RD
BALTIMORE MD
21230-1128
US

V. Phone/Fax

Practice location:
  • Phone: 443-600-4329
  • Fax:
Mailing address:
  • Phone: 443-600-4329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02328
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM04027
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: