Healthcare Provider Details

I. General information

NPI: 1982977633
Provider Name (Legal Business Name): JEA CATHERINE BRICKWEDDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 RIO RD W FA
CHARLOTTESVILLE VA
22901
US

IV. Provider business mailing address

716 RIO RD W FA
CHARLOTTESVILLE VA
22901
US

V. Phone/Fax

Practice location:
  • Phone: 434-960-5153
  • Fax: 434-964-0865
Mailing address:
  • Phone: 434-960-5153
  • Fax: 434-964-0865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2378804
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: