Provider Demographics
NPI:1639475031
Name:GRIFFIN, JESSE LEE (PHD, LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LEE
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:PHD, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6368 COVENTRY WAY
Mailing Address - Street 2:#386
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2256
Mailing Address - Country:US
Mailing Address - Phone:877-214-3668
Mailing Address - Fax:877-599-2585
Practice Address - Street 1:7700 OLD BRANCH AVE
Practice Address - Street 2:SUITE D103
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1628
Practice Address - Country:US
Practice Address - Phone:877-214-3668
Practice Address - Fax:877-599-2585
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LC3005101YM0800X
MDLC3005101YP1600X, 101YP2500X
DCPRC14059101YP2500X
VA0701004903101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD040066100Medicaid