Healthcare Provider Details

I. General information

NPI: 1174645790
Provider Name (Legal Business Name): MARTHA JEFFERSON HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 GORDON AVE
CHARLOTTESVILLE VA
22903-1918
US

IV. Provider business mailing address

1600 GORDON AVE
CHARLOTTESVILLE VA
22903-1918
US

V. Phone/Fax

Practice location:
  • Phone: 434-293-6136
  • Fax: 434-295-0400
Mailing address:
  • Phone: 434-293-6136
  • Fax: 434-295-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number000744
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH2625
License Number StateVA

VIII. Authorized Official

Name: HEATHER PARROTT
Title or Position: EXECUTIVE DIRECTOR
Credential: DHSC, LNHA, CCC-SLP
Phone: 434-293-6136