Healthcare Provider Details

I. General information

NPI: 1649107277
Provider Name (Legal Business Name): JAILYN RENEE PONZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 RIVER SHARK LN
WALDORF MD
20602-4227
US

IV. Provider business mailing address

5701 RIVER SHARK LN
WALDORF MD
20602-4227
US

V. Phone/Fax

Practice location:
  • Phone: 240-232-5914
  • Fax:
Mailing address:
  • Phone: 240-232-5914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: