Healthcare Provider Details

I. General information

NPI: 1275398679
Provider Name (Legal Business Name): JACQUELINE KATHLEEN DOUGLAS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2152 RENARD CT
ANNAPOLIS MD
21401-6756
US

IV. Provider business mailing address

31 WINDWARD DR
SEVERNA PARK MD
21146-2442
US

V. Phone/Fax

Practice location:
  • Phone: 410-980-2014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07058
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number07058
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: