Provider Demographics
NPI:1003144171
Name:BLACKWELL, JEANINNE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JEANINNE
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W PENNSYLVANIA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4507
Mailing Address - Country:US
Mailing Address - Phone:443-201-1991
Mailing Address - Fax:
Practice Address - Street 1:1010 DULANEY VALLEY RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2702
Practice Address - Country:US
Practice Address - Phone:410-567-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2313081363LP0808X, 363LP0808X
MDR205720363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health