Provider Demographics
NPI:1245237684
Name:KNODE, JENNIFER LYNN (PAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:KNODE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12070 OLD LINE CTR
Mailing Address - Street 2:STE 207
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2567
Mailing Address - Country:US
Mailing Address - Phone:301-870-0660
Mailing Address - Fax:301-932-8310
Practice Address - Street 1:12070 OLD LINE CTR
Practice Address - Street 2:STE 207
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2567
Practice Address - Country:US
Practice Address - Phone:301-870-0660
Practice Address - Fax:301-932-8310
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001763363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S52267Medicare UPIN
DC000D00P76Medicare ID - Type Unspecified
MD076DMedicare ID - Type Unspecified