Provider Demographics
NPI:1528606175
Name:DUTROW, JENNIFER VINE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:VINE
Last Name:DUTROW
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 1:4312 GREEN GLADE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1704
Mailing Address - Country:US
Mailing Address - Phone:410-215-9758
Mailing Address - Fax:
Practice Address - Street 1:1447 YORK RD STE 506
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6022
Practice Address - Country:US
Practice Address - Phone:410-825-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05358104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker