Provider Demographics
NPI:1770877201
Name:TROTTER, JACQUELINE R
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:TROTTER
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 1:409 LIBERTY CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-2215
Mailing Address - Country:US
Mailing Address - Phone:410-676-4291
Mailing Address - Fax:
Practice Address - Street 1:1101 N POINT BLVD
Practice Address - Street 2:STE 124
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3417
Practice Address - Country:US
Practice Address - Phone:410-285-8157
Practice Address - Fax:410-285-8298
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDREF# 480101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDREF#480OtherDHMH ALCOHOL AND DRUG TRAINEE CERTIFICATE