Healthcare Provider Details

I. General information

NPI: 1235714437
Provider Name (Legal Business Name): JACK CARTER SYKSTUS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MOUNT VERNON AVE
ALEXANDRIA VA
22301-1302
US

IV. Provider business mailing address

817 L ST NE
WASHINGTON DC
20002-3640
US

V. Phone/Fax

Practice location:
  • Phone: 202-960-4193
  • Fax:
Mailing address:
  • Phone: 256-690-8024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001799
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: