Healthcare Provider Details

I. General information

NPI: 1255194916
Provider Name (Legal Business Name): JACQUELINE BRODY LAURENZI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8245 BOONE BLVD STE 630
VIENNA VA
22182-3894
US

IV. Provider business mailing address

40996 BLOSSOM GLADE DR
ALDIE VA
20105-5827
US

V. Phone/Fax

Practice location:
  • Phone: 412-491-7140
  • Fax:
Mailing address:
  • Phone: 412-491-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704016693
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0704016693
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: