Healthcare Provider Details

I. General information

NPI: 1720801459
Provider Name (Legal Business Name): JMR MENTAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 KINGSWAY CT
GAMBRILLS MD
21054-2122
US

IV. Provider business mailing address

1486 KINGSWAY CT
GAMBRILLS MD
21054-2122
US

V. Phone/Fax

Practice location:
  • Phone: 580-649-9011
  • Fax:
Mailing address:
  • Phone: 580-649-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSECA RANDALL
Title or Position: OWNER
Credential: LCSW-C
Phone: 580-649-9011