Healthcare Provider Details

I. General information

NPI: 1992289425
Provider Name (Legal Business Name): JACOB LEVI PRILUCK PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 BRANDON AVE
SPRINGFIELD VA
22150-2522
US

IV. Provider business mailing address

1501 SULGRAVE AVE STE 209
BALTIMORE MD
21209-3650
US

V. Phone/Fax

Practice location:
  • Phone: 917-783-0634
  • Fax:
Mailing address:
  • Phone: 917-783-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006056
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810006056
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: