Provider Demographics
NPI:1245578053
Name:MOON, JENNIFER RACHELLE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RACHELLE
Last Name:MOON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:RACHELLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:9950 ROYAL COMMERCE PL
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1163
Mailing Address - Country:US
Mailing Address - Phone:301-233-8105
Mailing Address - Fax:
Practice Address - Street 1:6700 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20815-5302
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN68347363LF0000X
MDR150711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily