Provider Demographics
NPI:1245202134
Name:JENNEY, STEPHANIE JO (CPNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:JENNEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:J
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:PO BOX 79137
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0137
Mailing Address - Country:US
Mailing Address - Phone:757-668-7200
Mailing Address - Fax:757-668-9691
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7007
Practice Address - Fax:757-668-8658
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0075617363LP0200X
VA0024167363363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200003090AMedicaid
Q26060Medicare UPIN
OK241429502Medicare ID - Type Unspecified