Provider Demographics
NPI:1891156147
Name:BROCK, JENNIFER LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7969 ASHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2885
Mailing Address - Country:US
Mailing Address - Phone:703-792-7800
Mailing Address - Fax:703-792-5699
Practice Address - Street 1:7969 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2885
Practice Address - Country:US
Practice Address - Phone:703-792-7800
Practice Address - Fax:703-792-5699
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006513101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945247Medicaid