Provider Demographics
NPI:1861254732
Name:CANALES, JESSICA JAMIE (RESIDENT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JAMIE
Last Name:CANALES
Suffix:
Gender:F
Credentials:RESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7927 BEACH PLUM LN
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-5006
Mailing Address - Country:US
Mailing Address - Phone:361-425-3336
Mailing Address - Fax:
Practice Address - Street 1:200 LITTLE FALLS ST STE 306
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4302
Practice Address - Country:US
Practice Address - Phone:703-231-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016671101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor