Provider Demographics
NPI:1780164665
Name:JACQUELINE GUEVARA LLC
Entity type:Organization
Organization Name:JACQUELINE GUEVARA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:240-392-1684
Mailing Address - Street 1:8116 ARLINGTON BLVD # 206
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1002
Mailing Address - Country:US
Mailing Address - Phone:240-392-1684
Mailing Address - Fax:
Practice Address - Street 1:601 KING STREET, #260
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314
Practice Address - Country:US
Practice Address - Phone:240-392-1684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040094901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326559758Medicaid