Healthcare Provider Details

I. General information

NPI: 1619792520
Provider Name (Legal Business Name): KRISTIYANA JESSICA OWENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4714 ARCADIA DR STE 100-125
FREDERICK MD
21703-7662
US

IV. Provider business mailing address

4714 ARCADIA DR STE 100-125
FREDERICK MD
21703-7662
US

V. Phone/Fax

Practice location:
  • Phone: 855-935-3691
  • Fax:
Mailing address:
  • Phone: 855-935-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: