Provider Demographics
NPI:1104090547
Name:POWELL, JACK L (LCSW-C)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:POWELL
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GAY ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-1898
Mailing Address - Country:US
Mailing Address - Phone:410-228-7714
Mailing Address - Fax:410-228-8049
Practice Address - Street 1:310 GAY ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1898
Practice Address - Country:US
Practice Address - Phone:410-228-7714
Practice Address - Fax:410-228-8049
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD083581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD135953ZBFKMedicare PIN
MDVA05Medicare PIN