1619083110 NPI number — JENNIFER CHRISTA WILLOUGHBY PH.D.

Table of content: JENNIFER CHRISTA WILLOUGHBY PH.D. (NPI 1619083110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619083110 NPI number — JENNIFER CHRISTA WILLOUGHBY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLOUGHBY
Provider First Name:
JENNIFER
Provider Middle Name:
CHRISTA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619083110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEONARDTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20650-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-475-9660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41900 FENWICK ST
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
LEONARDTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20650-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-475-9660
Provider Business Practice Location Address Fax Number:
301-475-8810
Provider Enumeration Date:
08/21/2006

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: 103T00000X , with the licence number:  03600 , 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)

  • Identifier: 379528 . This is a "MDIPA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7729469 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: B950 0007 . This is a "CAREFIRST BCBS FEP & NCA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 262293000 . This is a "MAGELLAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 379528 . This is a "ALLIANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: PVPB114888 . This is a "APS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 379528 . This is a "GEHA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 379528 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 517B 60718903 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 379528 . This is a "OPTIMUM CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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