Healthcare Provider Details

I. General information

NPI: 1952138604
Provider Name (Legal Business Name): JARIUS DWAYNE DOUGLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 ANNAPOLIS RD STE F
ODENTON MD
21113-1387
US

IV. Provider business mailing address

219 CHARLESWOOD DR
ATOKA TN
38004-7802
US

V. Phone/Fax

Practice location:
  • Phone: 240-296-1370
  • Fax:
Mailing address:
  • Phone: 901-355-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: