Provider Demographics
NPI:1336561257
Name:ADAMS, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ADAMS
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 1:5621 WALTHER AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-3432
Mailing Address - Country:US
Mailing Address - Phone:410-254-6437
Mailing Address - Fax:
Practice Address - Street 1:5621 WALTHER AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-3432
Practice Address - Country:US
Practice Address - Phone:410-254-6437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD079491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical