Provider Demographics
NPI:1265531040
Name:MCKOWN, JENNIE BETH (PA)
Entity type:Individual
Prefix:MISS
First Name:JENNIE
Middle Name:BETH
Last Name:MCKOWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N WOLFE ST
Mailing Address - Street 2:HALSTED 600
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0005
Mailing Address - Country:US
Mailing Address - Phone:410-955-5353
Mailing Address - Fax:410-955-7363
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:HALSTED 600
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-5353
Practice Address - Fax:410-955-7363
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC03418OtherSTATE LICENSE