Provider Demographics
NPI:1639872997
Name:LEWIS BETTENDORF, JESSIE ANN (LGPC)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ANN
Last Name:LEWIS BETTENDORF
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7594
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7524 MAIN ST
Practice Address - Street 2:
Practice Address - City:SYKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21784-7594
Practice Address - Country:US
Practice Address - Phone:443-328-4946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13715101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional