Provider Demographics
NPI:1114039377
Name:JEN-JOHN INC
Entity Type:Organization
Organization Name:JEN-JOHN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-694-5292
Mailing Address - Street 1:PO BOX 1924
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:301-694-5292
Mailing Address - Fax:301-694-2319
Practice Address - Street 1:68 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE C
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-694-5292
Practice Address - Fax:301-694-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040701207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD279MMedicare PIN