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General NPI Number Information
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NPI Number | 1699178236
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Entity Type | Organization
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Legal Business Name | JAM LLC
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Dates
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Enumeration Date | 09/26/2014
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Last Update Date | 09/26/2014
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Provider Practice Location Address
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Address Line | 12809 10TH ST
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City | BOWIE
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State | MD
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Zip | 20720-3652
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Country | US
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Telephone | 240-507-2634
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6111
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City | LARGO
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State | MD
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Zip | 20792-6111
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Country | US
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Telephone | 240-507-2634
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | KEITH A THOMPSON
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Credential | LCPC
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Telephone | 240-507-2634
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC3682
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License Number State | MD
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