Provider Demographics
NPI:1467724013
Name:JESSE FAIRCHILD LLC
Entity Type:Organization
Organization Name:JESSE FAIRCHILD LLC
Other - Org Name:BODHI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:410-456-0142
Mailing Address - Street 1:2327 PULASKI HWY
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3706
Mailing Address - Country:US
Mailing Address - Phone:443-877-4044
Mailing Address - Fax:
Practice Address - Street 1:2327 PULASKI HWY
Practice Address - Street 2:SUITE 101B
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3706
Practice Address - Country:US
Practice Address - Phone:443-877-4044
Practice Address - Fax:443-505-7065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-29
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty