Healthcare Provider Details

I. General information

NPI: 1033362926
Provider Name (Legal Business Name): JESSE FASK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2008
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 POT SPRING RD VILA MARIA SCHOOL AT ST. VINCENTS
TIMONIUM MD
21093-2732
US

IV. Provider business mailing address

2600 POT SPRING RD VILA MARIA SCHOOL AT ST. VINCENTS
TIMONIUM MD
21093-2732
US

V. Phone/Fax

Practice location:
  • Phone: 410-252-3725
  • Fax:
Mailing address:
  • Phone: 410-252-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13392
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: