Healthcare Provider Details

I. General information

NPI: 1104809342
Provider Name (Legal Business Name): TARA C JERNEJCIC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S CENTER ST
THURMONT MD
21788-1945
US

IV. Provider business mailing address

100 S CENTER ST
THURMONT MD
21788-1945
US

V. Phone/Fax

Practice location:
  • Phone: 301-696-8801
  • Fax: 301-696-0186
Mailing address:
  • Phone: 301-696-8801
  • Fax: 301-696-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC005418
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: