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NPI Code Detail

MEDICARE: JESSICA PECK PSYD

MEDICARE: JESSICA PECK PSYD
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
1103T00000XPsychologist0810007241VA
2103T00000XPsychologist05857MD

General Provider Information

NPI Number : 1750630851
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA PECK PSYD
Provider Business Mailing Address
First Line : PO BOX 575
Second Line :
City : PORT TOBACCO
State : MD
Zip : 20677-0575
Country : US
Telephone Number : 240-780-8254
Fax Number :
Provider Business Practice Location Address
First Line : 3261 OLD WASHINGTON RD STE 2020
Second Line :
City : WALDORF
State : MD
Zip : 20602-3231
Country : US
Telephone Number : 240-780-8254
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/05/2012
Last Update Date : 09/26/2022

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