Healthcare Provider Details

I. General information

NPI: 1891138038
Provider Name (Legal Business Name): JESSICA TIBBETTS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 BRADDOCK RD
ANNANDALE VA
22003-6006
US

IV. Provider business mailing address

7010 BRADDOCK RD
ANNANDALE VA
22003-6006
US

V. Phone/Fax

Practice location:
  • Phone: 703-941-0780
  • Fax: 703-941-0780
Mailing address:
  • Phone: 703-941-0780
  • Fax: 703-941-0780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008053
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50079465
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: