Provider Demographics
NPI:1932216280
Name:WILKEN, JEFFREY ADAM (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ADAM
Last Name:WILKEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 HAMAKER CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2238
Mailing Address - Country:US
Mailing Address - Phone:703-876-0966
Mailing Address - Fax:703-876-1628
Practice Address - Street 1:3020 HAMAKER CT
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2238
Practice Address - Country:US
Practice Address - Phone:703-876-0966
Practice Address - Fax:703-876-1628
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3571103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC492131Medicare PIN