Basic Information
Provider Information | |||||||||
NPI: | 1104895226 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENNINGS | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | PETER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4904 WAKEFIELD CHAPEL RD | ||||||||
Address2: |   | ||||||||
City: | ANNANDALE | ||||||||
State: | VA | ||||||||
PostalCode: | 220034467 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7033095080 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11 HOPE RD | ||||||||
Address2: | #23 | ||||||||
City: | STAFFORD | ||||||||
State: | VA | ||||||||
PostalCode: | 225547202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5406580888 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0904005989 | VA | Y |   | Other Service Providers | Specialist |   |
No ID Information.