Provider Demographics
NPI:1982742219
Name:MAMMEN, JENNIFER SOPHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SOPHIE
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 E MONUMENT ST
Mailing Address - Street 2:SUITE 333
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0020
Mailing Address - Country:US
Mailing Address - Phone:410-955-3663
Mailing Address - Fax:410-955-8172
Practice Address - Street 1:1830 E MONUMENT ST
Practice Address - Street 2:SUITE 333
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0020
Practice Address - Country:US
Practice Address - Phone:410-955-3663
Practice Address - Fax:410-955-8172
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT3876207RE0101X
MDD66867207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD027769000Medicaid
MD170231ZAC3Medicare PIN