Basic Information
| Provider Information | |||||||||
| NPI: | 1538197017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | C.N.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 W. PRATT STREET | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141302 | ||||||||
| FaxNumber: | 4103283379 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 W REDWOOD ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286640 | ||||||||
| FaxNumber: | 4103282648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 06/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LW0102X | R150136 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 813301800 | 05 | MD | MEDICAID |