Provider Demographics
NPI:1710166897
Name:NEILSON, JACQUELINE ANN (LCP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:NEILSON
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 G ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3605
Mailing Address - Country:US
Mailing Address - Phone:703-838-4455
Mailing Address - Fax:703-838-5070
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-838-4455
Practice Address - Fax:703-838-5070
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003870103TC0700X
MD04466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical