=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790566917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY ADAM BLEVINS LPC-R, M.A., CCISM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2023
-----------------------------------------------------
Last Update Date | 10/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4229 LAFAYETTE CENTER DR STE 1675
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-1270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-326-4673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 631 LESLIE ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24354-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-817-9736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0704016324
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------