Healthcare Provider Details

I. General information

NPI: 1790304012
Provider Name (Legal Business Name): JESSICA HATCH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA HATCH

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

24 LIBERTY PKWY
BALTIMORE MD
21222-3850
US

V. Phone/Fax

Practice location:
  • Phone: 706-457-0681
  • Fax:
Mailing address:
  • Phone: 706-457-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR254008
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberGA268600
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: