=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700110780
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER A ULBRICHT PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2009
-----------------------------------------------------
Last Update Date | 03/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 DEWITT LOOP CHILD AND ADOLESCENT PSYCH, 2ND FLOOR, RIVER PAVILLION
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-231-1353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9300 DEWITT LOOP CHILD AND ADOLESCENT PSYCH, 2ND FLOOR, RIVER PAVILLION
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-231-1353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 0810004577
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 04785
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------