Provider Demographics
NPI:1427482942
Name:YOUDOM, JENNIFER LYNN (LCSW-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:YOUDOM
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:12145 ELM ST
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-1358
Practice Address - Country:US
Practice Address - Phone:410-651-2204
Practice Address - Fax:410-651-0790
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD192271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
MD119591300Medicaid
211862Medicare Oscar/Certification