Provider Demographics
NPI:1508364001
Name:JENIFER, NAKISHA
Entity Type:Individual
Prefix:
First Name:NAKISHA
Middle Name:
Last Name:JENIFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 POST OFFICE RD # 2394
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-9998
Mailing Address - Country:US
Mailing Address - Phone:240-719-8244
Mailing Address - Fax:
Practice Address - Street 1:11801 PARK WALDORF LN STE 510
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3191
Practice Address - Country:US
Practice Address - Phone:240-719-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR01689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist