Healthcare Provider Details

I. General information

NPI: 1316647431
Provider Name (Legal Business Name): MENTAL JOG THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 MCELDERRY ST
BALTIMORE MD
21205-2820
US

IV. Provider business mailing address

3317 MCELDERRY ST
BALTIMORE MD
21205-2820
US

V. Phone/Fax

Practice location:
  • Phone: 443-597-5027
  • Fax:
Mailing address:
  • Phone: 443-597-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MALIK DEVON JOHNSON
Title or Position: OWNER/THERAPIST
Credential: LCPC
Phone: 443-597-5027