Healthcare Provider Details

I. General information

NPI: 1093540965
Provider Name (Legal Business Name): JEWEL CHRISTINA CLARK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 EDUCATION CT
BROADLANDS VA
20148-5526
US

IV. Provider business mailing address

41872 RAWNSLEY DR
ASHBURN VA
20148-8040
US

V. Phone/Fax

Practice location:
  • Phone: 571-252-1000
  • Fax:
Mailing address:
  • Phone: 571-340-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: