Healthcare Provider Details

I. General information

NPI: 1598267700
Provider Name (Legal Business Name): KSA YOUTH FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10905 FORT WASHINGTON RD STE 105
FORT WASHINGTON MD
20744-5844
US

IV. Provider business mailing address

10905 FORT WASHINGTON RD STE 105
FORT WASHINGTON MD
20744-5844
US

V. Phone/Fax

Practice location:
  • Phone: 240-766-4194
  • Fax: 301-485-0363
Mailing address:
  • Phone: 240-766-4194
  • Fax: 301-485-0363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. KATRINA ANN WILKINS-JACKSON
Title or Position: CEO/OWNER
Credential:
Phone: 240-766-4194