Provider Demographics
NPI:1891422002
Name:ODURO, JACINTA
Entity type:Individual
Prefix:
First Name:JACINTA
Middle Name:
Last Name:ODURO
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 1:184 THOMAS JOHNSON DR STE 202L
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4564
Mailing Address - Country:US
Mailing Address - Phone:301-201-3181
Mailing Address - Fax:301-909-5995
Practice Address - Street 1:184 THOMAS JOHNSON DR STE 202L
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4564
Practice Address - Country:US
Practice Address - Phone:301-201-3181
Practice Address - Fax:301-909-5995
Is Sole Proprietor?:No
Enumeration Date:2022-08-07
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR254850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily