Basic Information
| Provider Information | |||||||||
| NPI: | 1699866723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 SUITLAND ROAD | ||||||||
| Address2: | |||||||||
| City: | MORNINGSIDE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017583685 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3900 LOCH RAVEN BOULEVARD | ||||||||
| Address2: | RM 1A-30 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
| FaxNumber: | 4106057589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19987 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.