Healthcare Provider Details

I. General information

NPI: 1306433198
Provider Name (Legal Business Name): JACQUELINE LYLE REIST LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12359 SUNRISE VALLEY DR STE 320
RESTON VA
20191-3463
US

IV. Provider business mailing address

12359 SUNRISE VALLEY DR STE 320
RESTON VA
20191-3463
US

V. Phone/Fax

Practice location:
  • Phone: 703-596-4796
  • Fax:
Mailing address:
  • Phone: 703-596-4796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701011418
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0704012975
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: