Healthcare Provider Details

I. General information

NPI: 1467724013
Provider Name (Legal Business Name): JESSE FAIRCHILD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2012
Last Update Date: 01/10/2026
Certification Date: 01/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2057 PULASKI HWY STE 4
NORTH EAST MD
21901-3744
US

IV. Provider business mailing address

2057 PULASKI HWY STE 4
NORTH EAST MD
21901-3744
US

V. Phone/Fax

Practice location:
  • Phone: 443-877-4044
  • Fax: 443-967-0077
Mailing address:
  • Phone: 443-877-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC2857
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: JANICE LESLIE FAIRCHILD CHAVERO
Title or Position: PRACTICE OWNER
Credential:
Phone: 443-877-4044