Provider Demographics
NPI:1982167185
Name:JAIN, ANJALI (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANJALI
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11247 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6736
Mailing Address - Country:US
Mailing Address - Phone:585-365-3659
Mailing Address - Fax:
Practice Address - Street 1:11247 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6736
Practice Address - Country:US
Practice Address - Phone:585-365-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty