Provider Demographics
NPI:1730102518
Name:JEFFERSON, PHILICIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILICIA
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:PHILICIA
Other - Middle Name:
Other - Last Name:JEFFERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 42111
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22404-2111
Mailing Address - Country:US
Mailing Address - Phone:703-490-1714
Mailing Address - Fax:
Practice Address - Street 1:4936 SOUTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-2659
Practice Address - Country:US
Practice Address - Phone:540-710-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA441462OtherANTHEM
VA005411041Medicaid
VA258225000OtherMAGELLAN
MD258225000OtherMEGALLEN