Basic Information
| Provider Information | |||||||||
| NPI: | 1114559036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13121 BROOKLANE DR | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13121 BROOKLANE DR | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2020 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 416133 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN.CNP.026720 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | R250262 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.