Healthcare Provider Details

I. General information

NPI: 1790828358
Provider Name (Legal Business Name): GLORIA LARSON-JADALI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 STEVENSON ST STEVENSON PLACE
FAIRFAX VA
22030-5617
US

IV. Provider business mailing address

10010 SUDLEY MANOR DR
MANASSAS VA
20109-6235
US

V. Phone/Fax

Practice location:
  • Phone: 703-460-6200
  • Fax: 703-277-7090
Mailing address:
  • Phone: 703-257-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0001078585
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: