Provider Demographics
NPI:1265735641
Name:SONG, JENNA MICHONG (RN)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHONG
Last Name:SONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8111 BROOKWOOD FARM RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-9658
Mailing Address - Country:US
Mailing Address - Phone:443-663-6223
Mailing Address - Fax:443-663-6131
Practice Address - Street 1:7141 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-1811
Practice Address - Country:US
Practice Address - Phone:443-663-6223
Practice Address - Fax:443-663-6131
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR100864163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management