Healthcare Provider Details

I. General information

NPI: 1609646298
Provider Name (Legal Business Name): JACL & ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15015 FIR ST
ACCOKEEK MD
20607-9776
US

IV. Provider business mailing address

15015 FIR ST
ACCOKEEK MD
20607-9776
US

V. Phone/Fax

Practice location:
  • Phone: 240-523-3147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHEVON MATHEWS-GREEN
Title or Position: CO-OWNER
Credential: LCPC
Phone: 240-523-3147