Provider Demographics
NPI:1619146081
Name:TAWIL, JACK NIMATALLAH (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:NIMATALLAH
Last Name:TAWIL
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 FOREST DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4430
Mailing Address - Country:US
Mailing Address - Phone:410-562-9647
Mailing Address - Fax:
Practice Address - Street 1:1831 FOREST DR
Practice Address - Street 2:SUITE F
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4430
Practice Address - Country:US
Practice Address - Phone:410-562-9647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD137251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD741421600659OtherCCN
MD003740U64OtherPTAN