Healthcare Provider Details

I. General information

NPI: 1558612010
Provider Name (Legal Business Name): JESSICA HART BASS LCPC, LCPAT, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA HART BYERLY MA

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 BROOKS DR STE 108
EASTON MD
21601-7474
US

IV. Provider business mailing address

8737 BROOKS DR STE 108
EASTON MD
21601-7474
US

V. Phone/Fax

Practice location:
  • Phone: 800-867-2395
  • Fax: 410-443-0842
Mailing address:
  • Phone: 800-867-2395
  • Fax: 410-443-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP5307
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberATC139
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC6290
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: