Provider Demographics
NPI:1609650225
Name:ARCHIBONG, JAMIE (MA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:ARCHIBONG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 HAMILTON AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-3828
Mailing Address - Country:US
Mailing Address - Phone:443-615-3548
Mailing Address - Fax:
Practice Address - Street 1:711 W 40TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2120
Practice Address - Country:US
Practice Address - Phone:410-517-7531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0765103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist