Provider Demographics
NPI:1528445590
Name:JUDY, JANSEN (LCADC)
Entity type:Individual
Prefix:
First Name:JANSEN
Middle Name:
Last Name:JUDY
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-4343
Mailing Address - Country:US
Mailing Address - Phone:301-334-7670
Mailing Address - Fax:301-334-7671
Practice Address - Street 1:1025 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-4343
Practice Address - Country:US
Practice Address - Phone:301-334-7670
Practice Address - Fax:301-334-7671
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA2245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional