Provider Demographics
NPI:1679789473
Name:SHOWALTER, JEFFERY RYAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:RYAN
Last Name:SHOWALTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYER
Mailing Address - State:VA
Mailing Address - Zip Code:22211-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 CARPENTER RD
Practice Address - Street 2:
Practice Address - City:FORT MYER
Practice Address - State:VA
Practice Address - Zip Code:22211-1009
Practice Address - Country:US
Practice Address - Phone:703-303-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007203103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical