Provider Demographics
NPI:1811576853
Name:PERDOMO, JACQELINE VANESA
Entity Type:Individual
Prefix:
First Name:JACQELINE
Middle Name:VANESA
Last Name:PERDOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENARDEN
Mailing Address - State:MD
Mailing Address - Zip Code:20706-6312
Mailing Address - Country:US
Mailing Address - Phone:301-970-9678
Mailing Address - Fax:
Practice Address - Street 1:4500 FORBES BLVD
Practice Address - Street 2:
Practice Address - City:GLENARDEN
Practice Address - State:MD
Practice Address - Zip Code:20706-6312
Practice Address - Country:US
Practice Address - Phone:301-970-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician