MEDICARE: JENNIFER SUSSAL LGSW

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	23272	MD

General Provider Information

NPI Number	:	1871091124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER SUSSAL LGSW

Provider Business Mailing Address
First Line	:	2705 SILVER HAMMER WAY
Second Line	:
City	:	BROOKEVILLE
State	:	MD
Zip	:	20833-3244
Country	:	US
Telephone Number	:	631-512-2610
Fax Number	:

Provider Business Practice Location Address
First Line	:	10705 CHARTER DR STE 410
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-2800
Country	:	US
Telephone Number	:	443-653-1363
Fax Number	:

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

Provider Enumeration Date	:	01/31/2018
Last Update Date	:	01/31/2018

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