Healthcare Provider Details

I. General information

NPI: 1467950980
Provider Name (Legal Business Name): JILL SHEPPARD DAVENPORT MS, MPP, LN, LDN,CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 07/17/2025
Certification Date:
Deactivation Date: 10/11/2024
Reactivation Date: 07/17/2025

III. Provider practice location address

10801 HICKORY RIDGE RD SUITE 215 C/O HOLISTIC CHILD PSYCHIATRY
COLUMBIA MD
21044
US

IV. Provider business mailing address

10801 HICKORY RIDGE RD SUITE 215 C/O HOLISTIC CHILD PSYCHIATRY
COLUMBIA MD
21044
US

V. Phone/Fax

Practice location:
  • Phone: 202-567-7783
  • Fax:
Mailing address:
  • Phone: 202-567-7783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX4347
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDX4347
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: