Healthcare Provider Details

I. General information

NPI: 1114210846
Provider Name (Legal Business Name): JASON J ZODDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 WILLOW OAKS CORPORATE DR EMERGENCY SERVICES
FAIRFAX VA
22031-4512
US

IV. Provider business mailing address

8221 WILLOW OAKS CORPORATE DR EMERGENCY SERVICES
FAIRFAX VA
22031-4512
US

V. Phone/Fax

Practice location:
  • Phone: 703-573-5679
  • Fax:
Mailing address:
  • Phone: 703-573-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number020252
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005148
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: