Provider Demographics
NPI:1790566917
Name:BLEVINS, JEFFREY ADAM (LPC-R, MA, CCISM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ADAM
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:LPC-R, MA, CCISM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 LESLIE ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-2211
Mailing Address - Country:US
Mailing Address - Phone:540-817-9736
Mailing Address - Fax:
Practice Address - Street 1:4229 LAFAYETTE CENTER DR STE 1675
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1270
Practice Address - Country:US
Practice Address - Phone:855-326-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016324101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health