Healthcare Provider Details

I. General information

NPI: 1861001992
Provider Name (Legal Business Name): HEALTHY MINDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST RD STE 300
TOWSON MD
21204-2370
US

IV. Provider business mailing address

5214 DAYBROOK CIR APT 348
ROSEDALE MD
21237-5043
US

V. Phone/Fax

Practice location:
  • Phone: 240-468-8476
  • Fax:
Mailing address:
  • Phone: 240-468-8476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JACOBS JACQUETTE
Title or Position: MENTAL HEALTH THERAPIST
Credential:
Phone: 240-468-8476