Provider Demographics
NPI:1700489762
Name:GAINES, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 WOODSPRING DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1054
Mailing Address - Country:US
Mailing Address - Phone:443-504-3767
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:443-444-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212171363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care