Healthcare Provider Details

I. General information

NPI: 1144432931
Provider Name (Legal Business Name): JEFFREY O'DONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 TRIMBLE RD
JOPPA MD
21085-4035
US

IV. Provider business mailing address

2227 OLD EMMORTON ROAD SUITE 119
BEL AIR MD
21015
US

V. Phone/Fax

Practice location:
  • Phone: 410-893-4600
  • Fax: 410-569-0094
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number08599
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: