Healthcare Provider Details

I. General information

NPI: 1770634289
Provider Name (Legal Business Name): JENNIFER A FACTEAU LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 SUMMIT AVE
KENSINGTON MD
20895-2422
US

IV. Provider business mailing address

8045 BRIGHTWOOD CT
ELLICOTT CITY MD
21043-7934
US

V. Phone/Fax

Practice location:
  • Phone: 301-897-2373
  • Fax: 301-897-2373
Mailing address:
  • Phone: 443-807-3547
  • Fax: 443-807-3547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2293
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC14095
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: