Healthcare Provider Details

I. General information

NPI: 1841555323
Provider Name (Legal Business Name): JASON MICHAEL ZICK LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2524 KIRK AVE
BALTIMORE MD
21218-4826
US

IV. Provider business mailing address

109 N LINWOOD AVE
BALTIMORE MD
21224-1248
US

V. Phone/Fax

Practice location:
  • Phone: 410-467-6040
  • Fax:
Mailing address:
  • Phone: 443-812-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number18188
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: