Healthcare Provider Details

I. General information

NPI: 1205229333
Provider Name (Legal Business Name): JONES BRANCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7921 JONES BRANCH DR SUITE 400
MC LEAN VA
22102-3306
US

IV. Provider business mailing address

7921 JONES BRANCH DR SUITE 400
MC LEAN VA
22102-3306
US

V. Phone/Fax

Practice location:
  • Phone: 703-444-9141
  • Fax:
Mailing address:
  • Phone: 703-444-9141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1515
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number49D2044687
License Number StateVA

VIII. Authorized Official

Name: DR. VANESSA VERGNETTI
Title or Position: CEO
Credential: ND, PHD
Phone: 703-937-7169