Provider Demographics
NPI:1871091124
Name:SUSSAL, JENNIFER (LGSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SUSSAL
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 SILVER HAMMER WAY
Mailing Address - Street 2:
Mailing Address - City:BROOKEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20833-3244
Mailing Address - Country:US
Mailing Address - Phone:631-512-2610
Mailing Address - Fax:
Practice Address - Street 1:10705 CHARTER DR STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2800
Practice Address - Country:US
Practice Address - Phone:443-653-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD232721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical