Provider Demographics
NPI:1588128292
Name:BENTON, JACQUELINE LONGLEY (LGPC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LONGLEY
Last Name:BENTON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 CROWN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4515
Mailing Address - Country:US
Mailing Address - Phone:407-376-8977
Mailing Address - Fax:
Practice Address - Street 1:1208 E CHURCHVILLE RD STE 300
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3485
Practice Address - Country:US
Practice Address - Phone:410-893-4600
Practice Address - Fax:410-640-4358
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP6827101Y00000X
MDLC11602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor