Basic Information
Provider Information | |||||||||
NPI: | 1528436078 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | JESSIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSWC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13121 BROOK LANE | ||||||||
Address2: |   | ||||||||
City: | HAGERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 217421945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017330330 | ||||||||
FaxNumber: | 3017334038 | ||||||||
Practice Location | |||||||||
Address1: | 5301 BUCKEYSTOWN PIKE STE 170 | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217048380 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017330330 | ||||||||
FaxNumber: | 3017334038 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2015 | ||||||||
LastUpdateDate: | 01/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.