MEDICARE: JESSE FASK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	13392	MD

General Provider Information

NPI Number	:	1033362926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE FASK

Provider Business Mailing Address
First Line	:	2600 POT SPRING RD
Second Line	:	VILA MARIA SCHOOL AT ST. VINCENTS
City	:	TIMONIUM
State	:	MD
Zip	:	21093-2732
Country	:	US
Telephone Number	:	410-252-3725
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 POT SPRING RD
Second Line	:	VILA MARIA SCHOOL AT ST. VINCENTS
City	:	TIMONIUM
State	:	MD
Zip	:	21093-2732
Country	:	US
Telephone Number	:	410-252-3725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2008
Last Update Date	:	10/23/2008

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