Healthcare Provider Details

I. General information

NPI: 1346308277
Provider Name (Legal Business Name): JESSICA K HERIOT LCSWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 HARFORD RD SUITE 204 KILGALEN ASSOCIATES
FALLSTON MD
21047
US

IV. Provider business mailing address

1716 HARFORD RD SUITE 204
FALLSTON MD
21047
US

V. Phone/Fax

Practice location:
  • Phone: 410-877-7207
  • Fax: 410-877-7224
Mailing address:
  • Phone: 410-877-7207
  • Fax: 410-877-7224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00988
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierKC83K1
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
IdentifierT460
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerBLUE CHOICE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: