Provider Demographics
NPI:1487930442
Name:DOUGLAS, JENNIFER LYNN (CPM, LM)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:RUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:830 EAST RD.
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01247
Mailing Address - Country:US
Mailing Address - Phone:845-264-8724
Mailing Address - Fax:888-224-1413
Practice Address - Street 1:830 EAST RD.
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MA
Practice Address - Zip Code:01247
Practice Address - Country:US
Practice Address - Phone:845-264-8724
Practice Address - Fax:888-224-1413
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT107.0081441176B00000X
VT1070081441176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife