Provider Demographics
NPI:1265983563
Name:MALLOY, JENNIFER ANN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MALLOY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TEXAS STATION CT
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-8286
Mailing Address - Country:US
Mailing Address - Phone:410-828-7417
Mailing Address - Fax:410-828-4695
Practice Address - Street 1:1 TEXAS STATION CT
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-8286
Practice Address - Country:US
Practice Address - Phone:410-828-7417
Practice Address - Fax:410-828-4695
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007657363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD210213700Medicaid