Provider Demographics
NPI:1336498823
Name:WILLEY, JENNA MARIE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:WILLEY
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 1:29315 ERICKSON DR
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8651
Mailing Address - Country:US
Mailing Address - Phone:410-690-8181
Mailing Address - Fax:
Practice Address - Street 1:29520 CANVASBACK DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7124
Practice Address - Country:US
Practice Address - Phone:410-822-5007
Practice Address - Fax:410-822-5569
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19537104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7840093OtherAETNA
MD609500300Medicaid
MD346646OtherTRICARE/MHN
MD609550002Medicaid
MDR968OtherCAREFIRST