Provider Demographics
NPI:1083454458
Name:HAAS, JENNIFER LUCILLE (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LUCILLE
Last Name:HAAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LUCILLE
Other - Last Name:KOVALICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6445 ROCKLEDGE CT
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5449
Mailing Address - Country:US
Mailing Address - Phone:410-507-3278
Mailing Address - Fax:
Practice Address - Street 1:3120 GRACEFIELD RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-5810
Practice Address - Country:US
Practice Address - Phone:301-572-8372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist