Provider Demographics
NPI:1396865218
Name:JACKSON SPEEDIE, MARY L (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:JACKSON SPEEDIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2931 E BIDDLE ST
Mailing Address - Street 2:PATIENT ACCOUNTING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-3939
Mailing Address - Country:US
Mailing Address - Phone:443-923-1886
Mailing Address - Fax:443-923-1875
Practice Address - Street 1:707 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1832
Practice Address - Country:US
Practice Address - Phone:443-923-9200
Practice Address - Fax:443-923-9405
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD01655103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD36394001OtherCAREFIRST BC BS