Provider Demographics
NPI:1114210846
Name:ZODDA, JASON J
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:ZODDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Mailing Address - Street 2:EMERGENCY SERVICES
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4512
Mailing Address - Country:US
Mailing Address - Phone:703-573-5679
Mailing Address - Fax:
Practice Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:EMERGENCY SERVICES
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-573-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020252103TC0700X
VA0810005148103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical