Provider Demographics
NPI:1750467395
Name:CHILDERS, JACK C III (LPC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:CHILDERS
Suffix:III
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LOUDOUN ST SW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-2933
Mailing Address - Country:US
Mailing Address - Phone:703-771-4041
Mailing Address - Fax:
Practice Address - Street 1:7 LOUDOUN ST SW
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-2933
Practice Address - Country:US
Practice Address - Phone:703-771-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003420101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional