Provider Demographics
NPI:1205537248
Name:ANDERSON, JESSICA RANELL
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RANELL
Last Name:ANDERSON
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 1:5022 CAMPBELL BLVD STE L-M
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4969
Mailing Address - Country:US
Mailing Address - Phone:410-406-0109
Mailing Address - Fax:
Practice Address - Street 1:5022 CAMPBELL BLVD STE L-M
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4969
Practice Address - Country:US
Practice Address - Phone:410-406-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15174101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor