MEDICARE: JENNIFER MCLISH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904006843	VA

General Provider Information

NPI Number	:	1700136165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MCLISH LCSW

Provider Business Mailing Address
First Line	:	25 E MYRTLE ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-2205
Country	:	US
Telephone Number	:	202-281-4563
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 POWHATAN ST
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-1343
Country	:	US
Telephone Number	:	202-281-4563
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2012
Last Update Date	:	09/13/2012

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