MEDICARE: JESSICA F SUMMERS LCSW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904007055	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0904007055	OTHER	VA	STATE LICENSE BOARD OF HEALTH PROFESSIONS

General Provider Information

NPI Number	:	1548766231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA F SUMMERS LCSW LLC

Provider Business Mailing Address
First Line	:	2356 SCHENLEY DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-3318
Country	:	US
Telephone Number	:	434-466-6895
Fax Number	:

Provider Business Practice Location Address
First Line	:	9327 MIDLOTHIAN TPKE STE 2G
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23235-4944
Country	:	US
Telephone Number	:	804-277-9034
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JESSICA FAYE SUMMERS
Credential	:	LCSW
Telephone Number	:	434-466-6895

Provider Enumeration Date	:	04/02/2018
Last Update Date	:	04/02/2018

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