Healthcare Provider Details

I. General information

NPI: 1710711064
Provider Name (Legal Business Name): SOPHIE GAELLA JEUDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 LENFANT SQ SE
WASHINGTON DC
20020-6724
US

IV. Provider business mailing address

3808 CHARRED OAK DR
FORT WASHINGTON MD
20744-1310
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-2401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26677
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: