Provider Demographics
NPI:1568218238
Name:JETTON, KERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:JETTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:OCCOQUAN
Mailing Address - State:VA
Mailing Address - Zip Code:22125-0162
Mailing Address - Country:US
Mailing Address - Phone:571-331-1276
Mailing Address - Fax:
Practice Address - Street 1:308 POPLAR ALY STE A
Practice Address - Street 2:
Practice Address - City:OCCOQUAN
Practice Address - State:VA
Practice Address - Zip Code:22125-7748
Practice Address - Country:US
Practice Address - Phone:571-331-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1114961041C0700X
VA090401154561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical