Provider Demographics
NPI:1265143978
Name:JACKSON, GWENDOLYN RACHELLE I
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:RACHELLE
Last Name:JACKSON
Suffix:I
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 1:5804 BELLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-3203
Mailing Address - Country:US
Mailing Address - Phone:443-480-5895
Mailing Address - Fax:
Practice Address - Street 1:23 THOMAS SHILLING CT
Practice Address - Street 2:
Practice Address - City:UPPERCO
Practice Address - State:MD
Practice Address - Zip Code:21155-9334
Practice Address - Country:US
Practice Address - Phone:443-901-6739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician