Provider Demographics
NPI:1730678632
Name:LUSK, JACQUELYN CLARISSA (SW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:CLARISSA
Last Name:LUSK
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 BRADDOCK PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1693
Mailing Address - Country:US
Mailing Address - Phone:703-706-4440
Mailing Address - Fax:
Practice Address - Street 1:1340 BRADDOCK PLACE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314
Practice Address - Country:US
Practice Address - Phone:703-706-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool