Provider Demographics
NPI:1952138604
Name:DOUGLAS, JARIUS DWAYNE
Entity type:Individual
Prefix:
First Name:JARIUS
Middle Name:DWAYNE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 CHARLESWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-7802
Mailing Address - Country:US
Mailing Address - Phone:901-355-5455
Mailing Address - Fax:
Practice Address - Street 1:1202 ANNAPOLIS RD STE F
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1387
Practice Address - Country:US
Practice Address - Phone:240-296-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health