Provider Demographics
NPI:1063471134
Name:RUIZ, JEAN H (NP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:H
Last Name:RUIZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12502 WILLOWBROOK RD
Mailing Address - Street 2:STE 380
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6592
Mailing Address - Country:US
Mailing Address - Phone:240-964-8585
Mailing Address - Fax:240-964-8586
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:STE 380
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6592
Practice Address - Country:US
Practice Address - Phone:240-964-8585
Practice Address - Fax:240-964-8586
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166119363L00000X
MDR197967363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA137118OtherANTHEM
VA010088682Medicaid
VA003156W68Medicare PIN
VAQ03214Medicare UPIN