Provider Demographics
NPI:1174872642
Name:MCMILLAN, JENNIFER COSTA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:COSTA
Last Name:MCMILLAN
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 1:1122 KENILWORTH DR STE 416
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2148
Mailing Address - Country:US
Mailing Address - Phone:443-451-5122
Mailing Address - Fax:
Practice Address - Street 1:1012 S NORTH POINT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3338
Practice Address - Country:US
Practice Address - Phone:443-216-4800
Practice Address - Fax:443-216-4801
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health