Provider Demographics
NPI:1952052508
Name:VENDA JALLAD, JENNIFER LEAH (CRNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEAH
Last Name:VENDA JALLAD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 NATIONAL HWY SW STE 5&6
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6573
Mailing Address - Country:US
Mailing Address - Phone:443-761-1106
Mailing Address - Fax:
Practice Address - Street 1:14701 NATIONAL HWY SW STE 5&6
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-6573
Practice Address - Country:US
Practice Address - Phone:304-303-9841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR223266163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty