Healthcare Provider Details

I. General information

NPI: 1144965591
Provider Name (Legal Business Name): JESSICA GERGIS RYDER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA GERGIS

II. Dates (important events)

Enumeration Date: 04/30/2022
Last Update Date: 03/22/2025
Certification Date: 03/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10306 EATON PL STE 300
FAIRFAX VA
22030-2201
US

IV. Provider business mailing address

10306 EATON PL STE 300
FAIRFAX VA
22030-2201
US

V. Phone/Fax

Practice location:
  • Phone: 703-493-0378
  • Fax:
Mailing address:
  • Phone: 703-493-0378
  • Fax: 757-452-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701014607
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: