Provider Demographics
NPI:1174392401
Name:DONALDSON, JENNIFER L (CSC-AD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DONALDSON
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 COLESBURY PL
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-4019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 LANGLEY RD N
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-6531
Practice Address - Country:US
Practice Address - Phone:410-222-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC3251101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)