Provider Demographics
NPI:1467135103
Name:DAVIS, JEREMY BENJAMIN
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BENJAMIN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10630 LITTLE PATUXENT PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3264
Mailing Address - Country:US
Mailing Address - Phone:410-740-8067
Mailing Address - Fax:410-740-8068
Practice Address - Street 1:10630 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3264
Practice Address - Country:US
Practice Address - Phone:410-740-8067
Practice Address - Fax:410-740-8068
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional