Provider Demographics
NPI:1114559036
Name:DOUGLAS, JENNIFER G (CRNP, PMHNP, FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:CRNP, PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10055 RED RUN BLVD STE 20033
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4892
Mailing Address - Country:US
Mailing Address - Phone:240-345-1055
Mailing Address - Fax:240-752-0849
Practice Address - Street 1:10055 RED RUN BLVD STE 20033
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4892
Practice Address - Country:US
Practice Address - Phone:240-345-1055
Practice Address - Fax:240-752-0849
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH416133363LF0000X
MDR250262363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty