Healthcare Provider Details

I. General information

NPI: 1922716711
Provider Name (Legal Business Name): MARCELLA JACKSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 01/07/2023
Certification Date: 01/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8831 SATYR HILL RD STE 107
BALTIMORE MD
21234-2437
US

IV. Provider business mailing address

8831 SATYR HILL RD STE 107
BALTIMORE MD
21234-2437
US

V. Phone/Fax

Practice location:
  • Phone: 443-838-1700
  • Fax:
Mailing address:
  • Phone: 443-838-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number18439
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number18439
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18439
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number18439
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number18439
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: