Healthcare Provider Details

I. General information

NPI: 1972174258
Provider Name (Legal Business Name): JAXCYN THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 EDGEWOOD RD
BALTIMORE MD
21215-7230
US

IV. Provider business mailing address

1520 BELLE VIEW BLVD # 5011
ALEXANDRIA VA
22307-6530
US

V. Phone/Fax

Practice location:
  • Phone: 571-867-0075
  • Fax: 202-318-0667
Mailing address:
  • Phone: 571-867-0075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TA'WANE WATKINS
Title or Position: THERAPIST
Credential: LICSW
Phone: 571-867-0075