Provider Demographics
NPI:1508265737
Name:SULLIVAN, JESSICA PAGE (CRNP-PMH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:PAGE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNNE
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 W MADISON ST STE 11
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-2313
Mailing Address - Country:US
Mailing Address - Phone:443-438-7863
Mailing Address - Fax:
Practice Address - Street 1:10 W MADISON ST STE 11
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:443-438-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR192427363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD086453600Medicaid