Provider Demographics
NPI:1861920282
Name:EJIM, JACQUELINE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:EJIM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6918 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3854
Mailing Address - Country:US
Mailing Address - Phone:443-731-2349
Mailing Address - Fax:
Practice Address - Street 1:7902 BELAIR RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-3707
Practice Address - Country:US
Practice Address - Phone:443-731-2349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health