Healthcare Provider Details

I. General information

NPI: 1710166897
Provider Name (Legal Business Name): JACQUELINE ANN NEILSON LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N SAINT ASAPH ST
ALEXANDRIA VA
22314-1912
US

IV. Provider business mailing address

719 G ST NE
WASHINGTON DC
20002-3605
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-4455
  • Fax: 703-838-5070
Mailing address:
  • Phone: 703-838-4455
  • Fax: 703-838-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003870
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04466
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: