Healthcare Provider Details

I. General information

NPI: 1144625005
Provider Name (Legal Business Name): ANN JACOB SMITH LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 WISCONSIN AVE SUITE 210
CHEVY CHASE MD
20815-3530
US

IV. Provider business mailing address

5480 WISCONSIN AVE SUITE 210
CHEVY CHASE MD
20815-3530
US

V. Phone/Fax

Practice location:
  • Phone: 240-753-3775
  • Fax:
Mailing address:
  • Phone: 240-753-3775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC1960
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: