Healthcare Provider Details

I. General information

NPI: 1699892752
Provider Name (Legal Business Name): AMY M JEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENT AVE STE 102
CUMBERLAND MD
21502-3798
US

IV. Provider business mailing address

PO BOX 1671
CUMBERLAND MD
21501-1671
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-4288
  • Fax: 240-964-4280
Mailing address:
  • Phone: 240-964-8342
  • Fax: 240-964-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD440312
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number23853
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberD0093127
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: