Provider Demographics
NPI:1093064073
Name:JAIN, AMEENA (CRNP)
Entity Type:Individual
Prefix:MS
First Name:AMEENA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 S NORTH POINT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3338
Mailing Address - Country:US
Mailing Address - Phone:443-216-4800
Mailing Address - Fax:
Practice Address - Street 1:1012 S NORTH POINT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3338
Practice Address - Country:US
Practice Address - Phone:443-216-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX764950363LP0808X
MDR211311363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX306307501Medicaid
TXTXB164332Medicare PIN