Healthcare Provider Details

I. General information

NPI: 1366891806
Provider Name (Legal Business Name): JAIME M FENTON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W CHESAPEAKE AVE SECOND FLOOR
TOWSON MD
21204-4410
US

IV. Provider business mailing address

312 W CHESAPEAKE AVE SECOND FLOOR
TOWSON MD
21204-4410
US

V. Phone/Fax

Practice location:
  • Phone: 443-602-6426
  • Fax:
Mailing address:
  • Phone: 443-602-6426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4435
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: