Provider Demographics
NPI:1700321957
Name:JACOBS PROMISE
Entity type:Organization
Organization Name:JACOBS PROMISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-576-5487
Mailing Address - Street 1:15480 ANNAPOLIS RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1803
Mailing Address - Country:US
Mailing Address - Phone:301-392-7075
Mailing Address - Fax:
Practice Address - Street 1:15480 ANNAPOLIS RD STE 202
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1803
Practice Address - Country:US
Practice Address - Phone:301-392-7075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-26
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDZZ 103K00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization