Basic Information
| Provider Information | |||||||||
| NPI: | 1710166897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEILSON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 719 G ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200023605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038384455 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 N SAINT ASAPH ST | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223141912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038384455 | ||||||||
| FaxNumber: | 7038385070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810003870 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 04466 | MD | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.