Provider Demographics
NPI:1215529805
Name:JAE3 HEALTH AND WELLNESS LLC
Entity type:Organization
Organization Name:JAE3 HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:J
Authorized Official - Last Name:KALLON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:240-691-9840
Mailing Address - Street 1:9607 OXBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721
Mailing Address - Country:US
Mailing Address - Phone:240-691-9840
Mailing Address - Fax:
Practice Address - Street 1:9607 OXBRIDGE WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721
Practice Address - Country:US
Practice Address - Phone:240-691-9840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty