Provider Demographics
NPI:1174314959
Name:GRANT, JACQUELINE YVONNE (LGPC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:YVONNE
Last Name:GRANT
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 LANIER AVE
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-6218
Mailing Address - Country:US
Mailing Address - Phone:434-426-6494
Mailing Address - Fax:434-426-6494
Practice Address - Street 1:5563 LANIER AVE
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-6218
Practice Address - Country:US
Practice Address - Phone:434-426-6494
Practice Address - Fax:434-426-6494
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15015101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health