Basic Information
| Provider Information | |||||||||
| NPI: | 1154409555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBBINS | ||||||||
| FirstName: | JENIFER | ||||||||
| MiddleName: | STACEY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FAMILY ADVOCATE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOOB | ||||||||
| OtherFirstName: | JENIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Practice Location | |||||||||
| Address1: | 29520 CANVASBACK DR | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108225007 | ||||||||
| FaxNumber: | 4108225569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 517251 | 01 | UHC MAMSI GROUP# | OTHER | 609500300 | 05 | MD | MEDICAID | 609550002 | 05 | MD | MEDICAID | 609500303 | 05 | MD | MEDICAID | R968 | 01 | CAREFIRST FEDERAL GROUP | OTHER | 259147000 | 01 | MD | MAGELLAN GROUP | OTHER | 609500301 | 05 | MD | MEDICAID | 609550001 | 05 | MD | MEDICAID | LM49EA | 01 | MD | CAREFIRST BCBS GROUP | OTHER |