Provider Demographics
NPI:1689334773
Name:ETHRIDGE, JEANETTE (NP)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:
Last Name:ETHRIDGE
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 1:7522 GREER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-3319
Mailing Address - Country:US
Mailing Address - Phone:301-648-5725
Mailing Address - Fax:
Practice Address - Street 1:7522 GREER DR
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-3319
Practice Address - Country:US
Practice Address - Phone:301-648-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1006588163W00000X
DCNP1006588363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse