Healthcare Provider Details

I. General information

NPI: 1902135684
Provider Name (Legal Business Name): WASHINTON NEUROPSYCHOLOGY RESEARCH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 HAMAKER CT SUITE 103
FAIRFAX VA
22031-2238
US

IV. Provider business mailing address

2629 OAKTON GLEN DR
VIENNA VA
22181-5344
US

V. Phone/Fax

Practice location:
  • Phone: 703-876-0966
  • Fax: 703-876-1628
Mailing address:
  • Phone: 703-876-0966
  • Fax: 703-876-1628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810003702
License Number StateVA

VIII. Authorized Official

Name: DR. JEFFREY ADAM WILKEN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 703-876-0966