Healthcare Provider Details

I. General information

NPI: 1346977204
Provider Name (Legal Business Name): JEFFREY PERCACCIANTE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 TIDEWATER COLONY DR STE 1A
ANNAPOLIS MD
21401-2102
US

IV. Provider business mailing address

2007 TIDEWATER COLONY DR STE 1A
ANNAPOLIS MD
21401-2102
US

V. Phone/Fax

Practice location:
  • Phone: 410-294-9300
  • Fax:
Mailing address:
  • Phone: 410-294-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28954
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: