Healthcare Provider Details

I. General information

NPI: 1932641511
Provider Name (Legal Business Name): J&D FANT FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15113 S JENKINS CT
ACCOKEEK MD
20607-2001
US

IV. Provider business mailing address

15113 S JENKINS CT
ACCOKEEK MD
20607-2001
US

V. Phone/Fax

Practice location:
  • Phone: 318-791-0022
  • Fax:
Mailing address:
  • Phone: 318-791-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEITRA L FANT
Title or Position: THERAPIST/ VICE PRESIDENT
Credential: QMHP, MA
Phone: 318-791-0022