Provider Demographics
NPI:1063172393
Name:CHILDRESS, JENNIFER WALTERS (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WALTERS
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5824 OAK LEATHER DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2433
Mailing Address - Country:US
Mailing Address - Phone:443-848-6333
Mailing Address - Fax:
Practice Address - Street 1:10777 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6903
Practice Address - Country:US
Practice Address - Phone:443-848-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022172061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist