Healthcare Provider Details

I. General information

NPI: 1366969958
Provider Name (Legal Business Name): JACOB LEO LAWSON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 RIVERSIDE DR STE A204
SALISBURY MD
21801-4704
US

IV. Provider business mailing address

PO BOX 1978
SALISBURY MD
21802-1978
US

V. Phone/Fax

Practice location:
  • Phone: 443-358-6193
  • Fax: 443-358-6197
Mailing address:
  • Phone: 410-749-1015
  • Fax: 410-749-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number25282
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: