Provider Demographics
NPI:1629551239
Name:HAMILTON, JACQUELINE D (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:D
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16208 PENTERRA WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1919
Mailing Address - Country:US
Mailing Address - Phone:301-996-1677
Mailing Address - Fax:
Practice Address - Street 1:16208 PENTERRA WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1919
Practice Address - Country:US
Practice Address - Phone:301-996-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD510345101YA0400X
MDLC4137101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD441512400Medicaid