MEDICARE: JESSICA RICHARD QP, MSW, PLCSW

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	P007454	NC

General Provider Information

NPI Number	:	1356604185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA RICHARD QP, MSW, PLCSW

Provider Business Mailing Address
First Line	:	4508 BRACADA DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27705-1653
Country	:	US
Telephone Number	:	919-351-5325
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 BACK ACRE CIR STE 290B
Second Line	:
City	:	MOUNT AIRY
State	:	MD
Zip	:	21771-7769
Country	:	US
Telephone Number	:	301-703-8767
Fax Number	:	301-703-8886

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

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	05/13/2020

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