Individual
SHADIASE JACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
41900 FENWICK ST, LEONARDTOWN, MD 20650-3814
(301) 475-8860
Mailing address
41900 FENWICK ST, LEONARDTOWN, MD 20650-3814
(301) 475-8860
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
19632
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
589561803
—
MD
Enumeration date
01/31/2014
Last updated
01/31/2014
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