Provider Demographics
NPI:1972794642
Name:CARLSON, JEANINE RUTH (PHD)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:RUTH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1487 CHAIN BRIDGE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-5723
Mailing Address - Country:US
Mailing Address - Phone:703-919-0917
Mailing Address - Fax:703-536-4693
Practice Address - Street 1:1487 CHAIN BRIDGE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5723
Practice Address - Country:US
Practice Address - Phone:703-919-0917
Practice Address - Fax:703-536-4693
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2073103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical