Provider Demographics
NPI:1316539414
Name:JENKINS, LILLIAN MAE
Entity Type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:MAE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6508 WAYSIDE PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2864
Mailing Address - Country:US
Mailing Address - Phone:703-785-4512
Mailing Address - Fax:
Practice Address - Street 1:8134 OLD KEENE MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1849
Practice Address - Country:US
Practice Address - Phone:703-569-8731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010062101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional