Provider Demographics
NPI:1770981185
Name:MADDOX-BYRD, JENNIFER MICHELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:MADDOX-BYRD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1815 SYCAMORE VALLEY DR APT 103
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4588
Mailing Address - Country:US
Mailing Address - Phone:646-465-1982
Mailing Address - Fax:
Practice Address - Street 1:1815 SYCAMORE VALLEY DR APT 103
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4588
Practice Address - Country:US
Practice Address - Phone:646-465-1982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00107972101YP2500X
NY92417104100000X
NY087515-011041C0700X
VA09040164191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker