Healthcare Provider Details

I. General information

NPI: 1053556209
Provider Name (Legal Business Name): JACQUELYN G STEPHENSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELYN HENDERSON CNM

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 GAINSBOROUGH SQ STE 201
CHESAPEAKE VA
23320-1714
US

IV. Provider business mailing address

667 KINGSBOROUGH SQ STE 101
CHESAPEAKE VA
23320-4999
US

V. Phone/Fax

Practice location:
  • Phone: 757-842-4620
  • Fax: 757-842-4621
Mailing address:
  • Phone: 757-842-4481
  • Fax: 757-312-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001137127
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024164424
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number0024164424
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: