Provider Demographics
NPI:1518365881
Name:EATON, JENNIFER HOLMES (CRNP-PEDS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:HOLMES
Last Name:EATON
Suffix:
Gender:F
Credentials:CRNP-PEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:5219 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:NEW CHURCH
Practice Address - State:VA
Practice Address - Zip Code:23415-3332
Practice Address - Country:US
Practice Address - Phone:757-824-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173574363LP0200X
MDR262555363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid