Healthcare Provider Details

I. General information

NPI: 1437922838
Provider Name (Legal Business Name): JESSICA MARIE EVANS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CAROLYN DR
CROSS JUNCTION VA
22625-2401
US

IV. Provider business mailing address

103 CAROLYN DR
CROSS JUNCTION VA
22625-2401
US

V. Phone/Fax

Practice location:
  • Phone: 540-327-0751
  • Fax:
Mailing address:
  • Phone: 540-327-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015966
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: