Provider Demographics
NPI:1114459435
Name:SHIELDS, JENNIFER EVELYN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EVELYN
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ARCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-1949
Mailing Address - Country:US
Mailing Address - Phone:941-779-4654
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6662
Practice Address - Fax:410-328-6046
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD00910092083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program