Provider Demographics
NPI:1174778740
Name:CARDWELL, JESSICA LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:CARDWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8140 ASHTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-5698
Mailing Address - Country:US
Mailing Address - Phone:307-763-2415
Mailing Address - Fax:703-368-8454
Practice Address - Street 1:8140 ASHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-5698
Practice Address - Country:US
Practice Address - Phone:307-763-2415
Practice Address - Fax:703-368-8454
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY471103T00000X
VA0810004230103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist