Healthcare Provider Details

I. General information

NPI: 1164069886
Provider Name (Legal Business Name): ASHANTIANA WILSHENA, JEMILA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2019
Last Update Date: 12/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 INDEPENDENCE PKWY STE 300
CHESAPEAKE VA
23320-5208
US

IV. Provider business mailing address

1408 QUIET CT
PORTSMOUTH VA
23701-3618
US

V. Phone/Fax

Practice location:
  • Phone: 757-776-0790
  • Fax:
Mailing address:
  • Phone: 757-289-9049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberA60633323
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: