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General NPI Number Information
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NPI Number | 1992031744
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Entity Type | Individual
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Provider Name | JENNIFER ANN MOSSGROVE PH.D.
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Gender | Female
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Dates
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Enumeration Date | 10/29/2009
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Last Update Date | 10/29/2009
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Provider Practice Location Address
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Address Line | 133 PARK ST NE
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City | VIENNA
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State | VA
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Zip | 22180-4602
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Country | US
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Telephone | 703-281-2657
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Fax |
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Provider Business Mailing Address
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Address Line | 11534 HEARTHSTONE CT
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City | RESTON
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State | VA
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Zip | 20191-4415
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Country | US
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Telephone | 571-243-8625
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810004163
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License Number State | VA
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