Provider Demographics
NPI:1497435762
Name:BUSS, JACLYN R (LGPC)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:R
Last Name:BUSS
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 BYRON DR
Mailing Address - Street 2:
Mailing Address - City:SMITHSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21783-1565
Mailing Address - Country:US
Mailing Address - Phone:301-992-7896
Mailing Address - Fax:
Practice Address - Street 1:1208 E CHURCHVILLE RD STE 300
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3485
Practice Address - Country:US
Practice Address - Phone:410-893-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR199312163W00000X
MDLGP14088101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse