Provider Demographics
NPI:1447596770
Name:BLAIR, JACQUELINE KESTER (MED, LGMFT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KESTER
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MED, LGMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PLEASANT RIDGE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-2560
Mailing Address - Country:US
Mailing Address - Phone:443-928-3298
Mailing Address - Fax:410-902-5941
Practice Address - Street 1:20 PLEASANT RIDGE DR
Practice Address - Street 2:SUITE A
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-2560
Practice Address - Country:US
Practice Address - Phone:443-928-3298
Practice Address - Fax:410-902-5941
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM447106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist