Healthcare Provider Details

I. General information

NPI: 1609223734
Provider Name (Legal Business Name): JESSICA ANN VICKERS LCPC, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 E MAIN ST
ELKTON MD
21921-5917
US

IV. Provider business mailing address

121 HOPEWELL DR
NORTH EAST MD
21901-3334
US

V. Phone/Fax

Practice location:
  • Phone: 443-203-9850
  • Fax:
Mailing address:
  • Phone: 443-203-9850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA3253
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC14779
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: