Provider Demographics
NPI:1720117401
Name:ZIMMERMAN, JACQUELYN ELAINE (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:ELAINE
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27429 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973
Mailing Address - Country:US
Mailing Address - Phone:302-536-1566
Mailing Address - Fax:
Practice Address - Street 1:3680 WARWICK RD
Practice Address - Street 2:
Practice Address - City:EAST NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21631-1420
Practice Address - Country:US
Practice Address - Phone:410-685-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0906101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405755400Medicaid