Basic Information
| Provider Information | |||||||||
| NPI: | 1467724013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JESSE FAIRCHILD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BODHI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2327 PULASKI HWY | ||||||||
| Address2: | SUITE 101B | ||||||||
| City: | NORTH EAST | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219013706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438774044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2327 PULASKI HWY | ||||||||
| Address2: | SUITE 101B | ||||||||
| City: | NORTH EAST | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219013706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438774044 | ||||||||
| FaxNumber: | 4435057065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2012 | ||||||||
| LastUpdateDate: | 01/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | FAIRCHILD | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4104560142 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LC2857 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.