Provider Demographics
NPI:1346626181
Name:VALLEJO, JACK (MSW, LCSWC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:MSW, LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1229
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-1229
Mailing Address - Country:US
Mailing Address - Phone:410-356-9200
Mailing Address - Fax:443-200-0267
Practice Address - Street 1:1311 LONDONTOWN BLVD
Practice Address - Street 2:SUITE # 130A
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6454
Practice Address - Country:US
Practice Address - Phone:410-356-9200
Practice Address - Fax:443-200-0267
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD072591041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool