Provider Demographics
NPI:1427531532
Name:TRANSFORMATIONAL TELEPSYCHIATRY
Entity type:Organization
Organization Name:TRANSFORMATIONAL TELEPSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LATESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-617-1552
Mailing Address - Street 1:16701 MELFORD BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4411
Mailing Address - Country:US
Mailing Address - Phone:202-617-1552
Mailing Address - Fax:410-674-2348
Practice Address - Street 1:16701 MELFORD BLVD STE 400
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4411
Practice Address - Country:US
Practice Address - Phone:202-617-1552
Practice Address - Fax:410-674-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health