Provider Demographics
NPI:1588217285
Name:DAHLE, JENNA NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICOLE
Last Name:DAHLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 WATKINS RUN CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-1952
Mailing Address - Country:US
Mailing Address - Phone:410-361-0951
Mailing Address - Fax:
Practice Address - Street 1:504 E RIDGEVILLE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5942
Practice Address - Country:US
Practice Address - Phone:301-703-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant