Provider Demographics
NPI:1033383955
Name:VIDAS, JENNIFER DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DOUGLAS
Last Name:VIDAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:DOUGLAS
Other - Last Name:VIDAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:255 ROCKVILLE PIKE STE 145
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-5136
Mailing Address - Country:US
Mailing Address - Phone:240-777-3852
Mailing Address - Fax:240-777-4806
Practice Address - Street 1:255 ROCKVILLE PIKE STE 145
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-5136
Practice Address - Country:US
Practice Address - Phone:240-777-3852
Practice Address - Fax:240-777-4806
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2825101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional