Healthcare Provider Details

I. General information

NPI: 1467135103
Provider Name (Legal Business Name): JEREMY BENJAMIN DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-3264
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-3264
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-8067
  • Fax: 410-740-8068
Mailing address:
  • Phone: 410-740-8067
  • Fax: 410-740-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: