Healthcare Provider Details

I. General information

NPI: 1295565190
Provider Name (Legal Business Name): UPSTREAM JOURNEYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 MILLENNIUM DR STE 300
BELCAMP MD
21017-1527
US

IV. Provider business mailing address

4690 MILLENNIUM DR STE 300
BELCAMP MD
21017-1527
US

V. Phone/Fax

Practice location:
  • Phone: 410-888-7740
  • Fax:
Mailing address:
  • Phone: 410-888-7740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JENDAYI GANTT
Title or Position: PRACTICE OWNER
Credential: DNP, CNM, PMHNP-BC
Phone: 410-888-7740