Healthcare Provider Details

I. General information

NPI: 1598972333
Provider Name (Legal Business Name): JEFFREY BRENTLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S WHITING ST STE 312
ALEXANDRIA VA
22304-3632
US

IV. Provider business mailing address

PO BOX 1933
ALEXANDRIA VA
22313-1933
US

V. Phone/Fax

Practice location:
  • Phone: 703-249-5160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078543
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: