Healthcare Provider Details

I. General information

NPI: 1154986388
Provider Name (Legal Business Name): JESSICA LYNN WINEBRENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 SPECTRUM DR
FREDERICK MD
21703-7362
US

IV. Provider business mailing address

1401 SUMMER SWEET LN
MOUNT AIRY MD
21771-5576
US

V. Phone/Fax

Practice location:
  • Phone: 301-337-8833
  • Fax:
Mailing address:
  • Phone: 301-706-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-66727
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: