MEDICARE: JACK HOFMEISTER

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1598315822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK HOFMEISTER

Provider Business Mailing Address
First Line	:	6420 IVY TER
Second Line	:
City	:	ELKRIDGE
State	:	MD
Zip	:	21075-5831
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6420 IVY TER
Second Line	:
City	:	ELKRIDGE
State	:	MD
Zip	:	21075-5831
Country	:	US
Telephone Number	:	410-865-9376
Fax Number	:

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

Provider Enumeration Date	:	09/18/2019
Last Update Date	:	09/18/2019

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Directions to “ JACK HOFMEISTER ” Practice Location

Language	Start Address	Practice Location

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