Active NPI
Shadiase Jack
- Social Worker
- Leonardtown, MD
National Provider Identifier
1609299353
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Social Worker
- License
- 19632
- Practice address
- 41900 Fenwick St
Leonardtown, MD 20650-3814 - Phone
- (301) 475-8860
- NPI assigned
- Jan 31, 2014
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker | 104100000X | 19632 | MD | Primary |
Addresses
Primary practice location
41900 Fenwick St
Leonardtown, MD 20650-3814
Mailing address
41900 Fenwick St
Leonardtown, MD 20650-3814
Phone (301) 475-8860
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 589561803 | Medicaid | MD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19632 | MD | MD | Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1391126400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1391126400000",
"number": "1609299353",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "41900 FENWICK ST",
"city": "LEONARDTOWN",
"state": "MD",
"postal_code": "206503814",
"telephone_number": "301-475-8860"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "41900 FENWICK ST",
"city": "LEONARDTOWN",
"state": "MD",
"postal_code": "206503814",
"telephone_number": "301-475-8860"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACK",
"first_name": "SHADIASE",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2014-01-31",
"last_updated": "2014-01-31",
"status": "A"
},
"taxonomies": [
{
"code": "104100000X",
"taxonomy_group": "",
"desc": "Social Worker",
"state": "MD",
"license": "19632",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "589561803",
"state": "MD"
}
],
"endpoints": [],
"other_names": []
}Other providers in Leonardtown, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.