Provider Demographics
NPI:1194379784
Name:HIBBS, JESSICA SUSAN (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:SUSAN
Last Name:HIBBS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:SUSAN
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10026 MAIN ST BLDG 1
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3206
Mailing Address - Country:US
Mailing Address - Phone:410-973-2211
Mailing Address - Fax:443-782-0350
Practice Address - Street 1:10026 MAIN ST BLDG 1
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3206
Practice Address - Country:US
Practice Address - Phone:410-973-2211
Practice Address - Fax:443-782-0350
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9764101Y00000X
MDLC11740101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC11740OtherLICENSE
MD119591300Medicaid