Healthcare Provider Details

I. General information

NPI: 1225362734
Provider Name (Legal Business Name): ALBERT JEROME PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44110 ASHBURN SHOPPING PLAZA
ASHBURN VA
20147
US

IV. Provider business mailing address

43992 INDIAN FIELDS CT
LEESBURG VA
20176-1639
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-2999
  • Fax:
Mailing address:
  • Phone: 571-333-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004065
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: