Provider Demographics
NPI:1164622775
Name:BIRCHENOUGH, JENNIFER LYN (OTR, PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:BIRCHENOUGH
Suffix:
Gender:F
Credentials:OTR, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6934 AVIATION BLVD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2593
Mailing Address - Country:US
Mailing Address - Phone:443-949-0814
Mailing Address - Fax:
Practice Address - Street 1:6934 AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2593
Practice Address - Country:US
Practice Address - Phone:443-949-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005190363A00000X
MD6350225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist