Provider Demographics
NPI:1932641511
Name:J&D FANT FAMILY SERVICES
Entity Type:Organization
Organization Name:J&D FANT FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/ VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEITRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FANT
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP, MA
Authorized Official - Phone:318-791-0022
Mailing Address - Street 1:15113 S JENKINS CT
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-2001
Mailing Address - Country:US
Mailing Address - Phone:318-791-0022
Mailing Address - Fax:
Practice Address - Street 1:15113 S JENKINS CT
Practice Address - Street 2:
Practice Address - City:ACCOKEEK
Practice Address - State:MD
Practice Address - Zip Code:20607-2001
Practice Address - Country:US
Practice Address - Phone:318-791-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health