Healthcare Provider Details

I. General information

NPI: 1124436399
Provider Name (Legal Business Name): JENNIFER JOHNSON LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER TRUAX LCSW-C

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 EASTERN BLVD
BALTIMORE MD
21221-3422
US

IV. Provider business mailing address

3501 SINCLAIR LN SUITE 200A
BALTIMORE MD
21213-2029
US

V. Phone/Fax

Practice location:
  • Phone: 410-558-4700
  • Fax: 410-780-0364
Mailing address:
  • Phone: 410-558-4890
  • Fax: 410-534-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17030
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: