Provider Demographics
NPI:1184491953
Name:STEVENSON, JACQUELINE H (MSIOP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:H
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MSIOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W OSTEND ST STE 600
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3774
Mailing Address - Country:US
Mailing Address - Phone:866-500-0133
Mailing Address - Fax:866-500-0133
Practice Address - Street 1:145 W OSTEND ST STE 600
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3774
Practice Address - Country:US
Practice Address - Phone:866-500-0133
Practice Address - Fax:866-500-0133
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171M00000X, 103T00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional