Provider Demographics
NPI:1205512233
Name:PSONAK, JESSICA (DNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PSONAK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1213
Mailing Address - Country:US
Mailing Address - Phone:484-844-4111
Mailing Address - Fax:
Practice Address - Street 1:217 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1213
Practice Address - Country:US
Practice Address - Phone:484-844-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203989363LP0808X
COC-APN.0101024-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health