Provider Demographics
NPI:1114462843
Name:LAFAVE, JESSICA (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LAFAVE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:AVENUE A, BUILDING 22H
Mailing Address - Street 2:
Mailing Address - City:PERRY POINT
Mailing Address - State:MD
Mailing Address - Zip Code:21902
Mailing Address - Country:US
Mailing Address - Phone:410-642-2411
Mailing Address - Fax:
Practice Address - Street 1:4308 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-3116
Practice Address - Country:US
Practice Address - Phone:410-426-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21047101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health