Healthcare Provider Details

I. General information

NPI: 1316799208
Provider Name (Legal Business Name): JESSIE STEPHENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 PENNSYLVANIA AVE NW
WASHINGTON DC
20037-3201
US

IV. Provider business mailing address

2001 19TH ST NW APT 4
WASHINGTON DC
20009-1346
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-3000
  • Fax:
Mailing address:
  • Phone: 530-592-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: