Healthcare Provider Details

I. General information

NPI: 1871406322
Provider Name (Legal Business Name): JAELEN MYRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BROOKLEY AVE SW
BOLLING AFB DC
20032-7704
US

IV. Provider business mailing address

238 BROOKLEY AVE SW
BOLLING AFB DC
20032-7704
US

V. Phone/Fax

Practice location:
  • Phone: 202-404-1496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: