Provider Demographics
NPI:1194924217
Name:JAIN, RENUKA
Entity type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300B BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2128
Mailing Address - Country:US
Mailing Address - Phone:410-988-5171
Mailing Address - Fax:410-988-5349
Practice Address - Street 1:10300B BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2128
Practice Address - Country:US
Practice Address - Phone:410-988-5171
Practice Address - Fax:410-988-5349
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist