Provider Demographics
NPI:1538580949
Name:JERNIGAN, IVY DAMITA (MSW, LCSW-C)
Entity type:Individual
Prefix:MS
First Name:IVY
Middle Name:DAMITA
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:MSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7113 SANDOWN CIR
Mailing Address - Street 2:UNIT 201
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-8135
Mailing Address - Country:US
Mailing Address - Phone:443-414-7044
Mailing Address - Fax:
Practice Address - Street 1:401 HUNGERFORD DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4154
Practice Address - Country:US
Practice Address - Phone:240-777-3048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical