=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265044697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER REGENIA RIVERS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11614 AMARA PL
-----------------------------------------------------
City | LAKE RIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-7414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-438-1943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11614 AMARA PL
-----------------------------------------------------
City | LAKE RIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-7414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-438-1943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PRC14302
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701003755
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------