Provider Demographics
NPI:1831670405
Name:DOUGLAS, JIMMY II
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:DOUGLAS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9191 CARRIAGE HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4077
Mailing Address - Country:US
Mailing Address - Phone:512-554-4375
Mailing Address - Fax:
Practice Address - Street 1:9191 CARRIAGE HOUSE LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4077
Practice Address - Country:US
Practice Address - Phone:512-554-4375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8560101YP2500X
MDLC11605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38-3876389Medicaid