Provider Demographics
NPI:1598826034
Name:REDD, JACQUELYN LORRAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:LORRAINE
Last Name:REDD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:1396 PICCARD DR
Practice Address - Street 2:KAISER PERMANENTE SHADY GROVE MEDICAL CENTER
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4302
Practice Address - Country:US
Practice Address - Phone:301-548-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056903207RG0100X
DCMD20775207RG0100X
MDD0039754207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F00185Medicare UPIN
006985M92Medicare ID - Type Unspecified