Healthcare Provider Details

I. General information

NPI: 1326602061
Provider Name (Legal Business Name): JESSICA TYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E 25TH ST
BALTIMORE MD
21218-5213
US

IV. Provider business mailing address

5630 GOVANE AVE
BALTIMORE MD
21212-3911
US

V. Phone/Fax

Practice location:
  • Phone: 410-558-0019
  • Fax:
Mailing address:
  • Phone: 443-564-7794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number23141
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: