Healthcare Provider Details

I. General information

NPI: 1942924014
Provider Name (Legal Business Name): JILL MARION BREWER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N VAN DORN ST STE 128
ALEXANDRIA VA
22302-1601
US

IV. Provider business mailing address

2500 N VAN DORN ST STE 128
ALEXANDRIA VA
22302-1601
US

V. Phone/Fax

Practice location:
  • Phone: 703-894-4867
  • Fax:
Mailing address:
  • Phone: 703-894-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402204812
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: