Provider Demographics
NPI:1669470894
Name:DANIELS, JENNENE (LCSW-C, BCD)
Entity type:Individual
Prefix:MS
First Name:JENNENE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:LCSW-C, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6798 AMHERST RD
Mailing Address - Street 2:
Mailing Address - City:BRYANS ROAD
Mailing Address - State:MD
Mailing Address - Zip Code:20616-3046
Mailing Address - Country:US
Mailing Address - Phone:301-638-5001
Mailing Address - Fax:301-638-5003
Practice Address - Street 1:11315 PEMBROOKE SQ
Practice Address - Street 2:STE 112
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4806
Practice Address - Country:US
Practice Address - Phone:301-638-5001
Practice Address - Fax:301-638-5003
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD037911041C0700X
MA0089121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN
MD582M906FMedicare ID - Type Unspecified