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General NPI Number Information
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NPI Number | 1245014869
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Entity Type | Individual
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Provider Name | JENNIFER ANNE LISA PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 08/23/2023
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Last Update Date | 09/29/2025
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Provider Practice Location Address
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Address Line | 1576 MERRITT BLVD STE 8
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City | DUNDALK
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State | MD
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Zip | 21222-2114
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Country | US
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Telephone | 443-530-6921
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Fax |
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Provider Business Mailing Address
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Address Line | 1576 MERRITT BLVD STE 8
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City | DUNDALK
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State | MD
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Zip | 21222-2114
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Country | US
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Telephone | 443-530-6921
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | R178139
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License Number State | MD
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