Provider Demographics
NPI:1114597135
Name:HARDY, JALISA (HHP)
Entity Type:Individual
Prefix:MRS
First Name:JALISA
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:HHP
Other - Prefix:
Other - First Name:JALISA
Other - Middle Name:
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HHP
Mailing Address - Street 1:7537 RESCH LOOP
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6761
Mailing Address - Country:US
Mailing Address - Phone:410-564-6577
Mailing Address - Fax:
Practice Address - Street 1:7537 RESCH LOOP
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6761
Practice Address - Country:US
Practice Address - Phone:410-564-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD232674007