Healthcare Provider Details

I. General information

NPI: 1417879115
Provider Name (Legal Business Name): TIFFANY DE JONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23248 HICKOX DR
BRAMBLETON VA
20148-7299
US

IV. Provider business mailing address

23248 HICKOX DR
BRAMBLETON VA
20148-7299
US

V. Phone/Fax

Practice location:
  • Phone: 843-955-8525
  • Fax:
Mailing address:
  • Phone: 843-955-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019020958
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: