Provider Demographics
NPI:1033682786
Name:STINE, JENNIFER LEO (LCPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEO
Last Name:STINE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MIDSUMMER CT
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-4539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2603 N ROLLING RD STE 301-302
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-1975
Practice Address - Country:US
Practice Address - Phone:410-298-4642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8065101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC8065Medicaid