Healthcare Provider Details

I. General information

NPI: 1316539414
Provider Name (Legal Business Name): MS. LILLIAN MAE JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8134 OLD KEENE MILL RD STE 101
SPRINGFIELD VA
22152-1849
US

IV. Provider business mailing address

6508 WAYSIDE PL
ALEXANDRIA VA
22310-2864
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-8731
  • Fax:
Mailing address:
  • Phone: 703-785-4512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701010062
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: