Provider Demographics
NPI:1588008510
Name:WEAVER, JACQUELINE R (PSYD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 KERNAN DR OFC 1219
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6665
Mailing Address - Country:US
Mailing Address - Phone:410-448-2500
Mailing Address - Fax:410-448-6917
Practice Address - Street 1:2030 THISTLE HILL DR STE 202
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:PA
Practice Address - Zip Code:17362-1161
Practice Address - Country:US
Practice Address - Phone:717-843-7348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05792103G00000X, 103TC0700X
PAPS018080103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1841337805OtherHOSPITAL