Provider Demographics
NPI:1619083110
Name:WILLOUGHBY, JENNIFER CHRISTA (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHRISTA
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1608
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-1608
Mailing Address - Country:US
Mailing Address - Phone:301-475-9660
Mailing Address - Fax:
Practice Address - Street 1:41900 FENWICK ST
Practice Address - Street 2:SUITE #1
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3814
Practice Address - Country:US
Practice Address - Phone:301-475-9660
Practice Address - Fax:301-475-8810
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03600103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD379528OtherMDIPA
MD7729469OtherAETNA
MDB950 0007OtherCAREFIRST BCBS FEP & NCA
MD262293000OtherMAGELLAN
MD379528OtherALLIANCE
MDPVPB114888OtherAPS
MD379528OtherGEHA
MD379528OtherMAMSI
MD517B 60718903OtherCAREFIRST BCBS
MD379528OtherOPTIMUM CHOICE
MD379528OtherMDIPA
MD182N179GMedicare UPIN