Provider Demographics
NPI:1437508728
Name:JAMISON, TEDRA (PHD)
Entity Type:Individual
Prefix:
First Name:TEDRA
Middle Name:
Last Name:JAMISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HATCHETTS HILL RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1534
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:877-515-7147
Practice Address - Street 1:7 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-1626
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04680103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical