Healthcare Provider Details

I. General information

NPI: 1891949723
Provider Name (Legal Business Name): TIMOTHY JACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 PARK AVE STE 200
BALTIMORE MD
21201-5634
US

IV. Provider business mailing address

1040 PARK AVE STE 200
BALTIMORE MD
21201-5634
US

V. Phone/Fax

Practice location:
  • Phone: 443-738-0300
  • Fax: 443-738-0301
Mailing address:
  • Phone: 443-738-0300
  • Fax: 443-738-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0032712
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: