Healthcare Provider Details

I. General information

NPI: 1780845842
Provider Name (Legal Business Name): JESSIE STEPHEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2008
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SOLAREX CT SUITE 201
FREDERICK MD
21703-7005
US

IV. Provider business mailing address

604 SOLAREX CT SUITE 201
FREDERICK MD
21703-7005
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-8263
  • Fax: 301-682-5326
Mailing address:
  • Phone: 301-663-8263
  • Fax: 301-682-5326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD73447
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: