Provider Demographics
NPI:1073606141
Name:KOLODIN, JESSIE (RN, MS, CS-P)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:KOLODIN
Suffix:
Gender:F
Credentials:RN, MS, CS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E PADONIA RD STE 208
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2308
Mailing Address - Country:US
Mailing Address - Phone:410-628-8899
Mailing Address - Fax:
Practice Address - Street 1:30 E PADONIA RD STE 208
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2308
Practice Address - Country:US
Practice Address - Phone:410-628-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR092780363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner