1649559410 NPI number — MS. MARY GENNIFER JACKSON LCPC

Table of content: MS. MARY GENNIFER JACKSON LCPC (NPI 1649559410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649559410 NPI number — MS. MARY GENNIFER JACKSON LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MARY
Provider Middle Name:
GENNIFER
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
MARY
Provider Other Middle Name:
JACKSON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649559410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 PARK CENTER COURT
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-356-3344
Provider Business Mailing Address Fax Number:
410-356-4459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904-A WASHINGTON ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTMINSTER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-751-9205
Provider Business Practice Location Address Fax Number:
410-751-6191
Provider Enumeration Date:
08/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LC0855 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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