Healthcare Provider Details

I. General information

NPI: 1134837164
Provider Name (Legal Business Name): JENAE JOAN VACURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 SUDBROOK LN STE B
PIKESVILLE MD
21208-4184
US

IV. Provider business mailing address

4000 PENNYFIELDS LOCK CT
POINT OF ROCKS MD
21777-2083
US

V. Phone/Fax

Practice location:
  • Phone: 844-733-7823
  • Fax:
Mailing address:
  • Phone: 316-573-9078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number00126
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: