Provider Demographics
NPI:1265044697
Name:RIVERS, JENNIFER REGENIA (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REGENIA
Last Name:RIVERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11614 AMARA PL
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7414
Mailing Address - Country:US
Mailing Address - Phone:571-438-1943
Mailing Address - Fax:
Practice Address - Street 1:11614 AMARA PL
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7414
Practice Address - Country:US
Practice Address - Phone:571-438-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14302101YP2500X
VA0701003755101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional