Healthcare Provider Details

I. General information

NPI: 1912367806
Provider Name (Legal Business Name): JENNIFER FREDETTE MA, M.DIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 CHAIN BRIDGE RD
MC LEAN VA
22101-4322
US

IV. Provider business mailing address

PO BOX QQ
MC LEAN VA
22101-0700
US

V. Phone/Fax

Practice location:
  • Phone: 703-903-9696
  • Fax: 703-821-2505
Mailing address:
  • Phone: 703-903-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006603
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: