Provider Demographics
NPI:1841857307
Name:VICK, JENNIFER PAIGE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PAIGE
Last Name:VICK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22665 BRETMAR DR
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2229
Mailing Address - Country:US
Mailing Address - Phone:301-904-9422
Mailing Address - Fax:
Practice Address - Street 1:22326 EXPLORATION DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-2020
Practice Address - Country:US
Practice Address - Phone:301-904-9422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2304873-SUPV1041C0700X
ND67341041C0700X
MD321181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical