Provider Demographics
NPI:1396524849
Name:WATERS, JEANNIE FITZGERALD (MA, MED)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:FITZGERALD
Last Name:WATERS
Suffix:
Gender:F
Credentials:MA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11150 SUNSET HILLS RD STE 140
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5321
Mailing Address - Country:US
Mailing Address - Phone:703-471-5517
Mailing Address - Fax:703-481-8197
Practice Address - Street 1:11150 SUNSET HILLS RD STE 140
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5321
Practice Address - Country:US
Practice Address - Phone:703-471-5517
Practice Address - Fax:703-481-8197
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016065101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty