Provider Demographics
NPI:1609223734
Name:VICKERS, JESSICA ANN (LCPC, LCADC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:VICKERS
Suffix:
Gender:F
Credentials:LCPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N FRIENDSHIP CT
Mailing Address - Street 2:
Mailing Address - City:COLORA
Mailing Address - State:MD
Mailing Address - Zip Code:21917-1431
Mailing Address - Country:US
Mailing Address - Phone:443-880-4905
Mailing Address - Fax:
Practice Address - Street 1:24 N FRIENDSHIP CT
Practice Address - Street 2:
Practice Address - City:COLORA
Practice Address - State:MD
Practice Address - Zip Code:21917-1431
Practice Address - Country:US
Practice Address - Phone:443-880-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC14779101YP2500X
MDLCA3253101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD520202700Medicaid