Provider Demographics
NPI:1689074098
Name:PAGE, JENNA M (MED, ATC)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:M
Last Name:PAGE
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12716 CUNNINGHILL COVE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12716 CUNNINGHILL COVE RD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-1175
Practice Address - Country:US
Practice Address - Phone:410-952-9215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0126001088207PS0010X, 2255A2300X
MDA00009662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine