Provider Demographics
NPI:1861440448
Name:WHITMAN, JENNIFER I (PAC)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:I
Last Name:WHITMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:IEZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:77 THOMAS JOHNSON DR STE E
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4893
Mailing Address - Country:US
Mailing Address - Phone:301-695-8346
Mailing Address - Fax:301-624-5837
Practice Address - Street 1:77 THOMAS JOHNSON DR STE E
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4893
Practice Address - Country:US
Practice Address - Phone:301-695-8346
Practice Address - Fax:301-624-5837
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003331363A00000X
VA0110002079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S91427Medicare UPIN
S91427Medicare UPIN
VA010232015Medicaid