Provider Demographics
NPI:1265690986
Name:CHAN, JESSICA (LCSW)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8514 JEFFERSONIAN CT
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2378
Mailing Address - Country:US
Mailing Address - Phone:703-328-3563
Mailing Address - Fax:
Practice Address - Street 1:7643 LEESBURG PIKE
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-2530
Practice Address - Country:US
Practice Address - Phone:703-328-3563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040068411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904006841OtherCOMMONWEALTH OF VIRGINIA, DEPARTMENT OF HEALTH PROFESSIONS