Healthcare Provider Details

I. General information

NPI: 1932216280
Provider Name (Legal Business Name): JEFFREY ADAM WILKEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/13/2010
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

3020 HAMAKER CT SUITE 103
FAIRFAX VA
22031-2238
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 Number3571
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: