=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114868239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRILYN EVERLISA JANA FABIEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2026
-----------------------------------------------------
Last Update Date | 04/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6301 WHISTLERS PL
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20603-4361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-708-9321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6301 WHISTLERS PL
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20603-4361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-708-9321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LGP16200
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------