Provider Demographics
NPI:1538197017
Name:FAHEY, JENNIFER O (CNM)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:O
Last Name:FAHEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W. PRATT STREET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201
Mailing Address - Country:US
Mailing Address - Phone:667-214-1302
Mailing Address - Fax:410-328-3379
Practice Address - Street 1:419 W REDWOOD ST
Practice Address - Street 2:SUITE 500
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1734
Practice Address - Country:US
Practice Address - Phone:410-328-6640
Practice Address - Fax:410-328-2648
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
MDR150136363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD813301800Medicaid
MD813301800Medicaid