Provider Demographics
NPI:1316374333
Name:PROCTOR, JINA ELAINE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JINA
Middle Name:ELAINE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4578 SCOTTSDALE PL
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-4171
Mailing Address - Country:US
Mailing Address - Phone:301-404-9877
Mailing Address - Fax:
Practice Address - Street 1:601 MISSISSIPPI AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3862
Practice Address - Country:US
Practice Address - Phone:202-671-6426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3035111041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool