Provider Demographics
NPI:1629502786
Name:BAMBACH, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BAMBACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8967 YELLOW BRICK RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2303
Mailing Address - Country:US
Mailing Address - Phone:410-780-5203
Mailing Address - Fax:
Practice Address - Street 1:8967 YELLOW BRICK RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2303
Practice Address - Country:US
Practice Address - Phone:410-780-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR183111363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health