Provider Demographics
NPI:1972992501
Name:LANDIS, JESSICA H
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:LANDIS
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 1:7310 RITCHIE HWY
Mailing Address - Street 2:SUITE # 1009
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3065
Mailing Address - Country:US
Mailing Address - Phone:410-768-5988
Mailing Address - Fax:410-768-5989
Practice Address - Street 1:7310 RITCHIE HWY
Practice Address - Street 2:SUITE # 1009
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3065
Practice Address - Country:US
Practice Address - Phone:410-768-5988
Practice Address - Fax:410-768-5989
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health