Provider Demographics
NPI:1992050470
Name:DOUGLAS, JENNIFER LYNN (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10391 GREYSON LN
Mailing Address - Street 2:
Mailing Address - City:RIXEYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22737-1730
Mailing Address - Country:US
Mailing Address - Phone:540-937-2334
Mailing Address - Fax:540-937-7680
Practice Address - Street 1:2501 HUNTER PL STE 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3940
Practice Address - Country:US
Practice Address - Phone:703-659-9867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500781561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical