Healthcare Provider Details

I. General information

NPI: 1710730205
Provider Name (Legal Business Name): BECOME WHOLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 ROBERT FROST RD
CHESAPEAKE VA
23323-1345
US

IV. Provider business mailing address

605 ROBERT FROST RD
CHESAPEAKE VA
23323-1345
US

V. Phone/Fax

Practice location:
  • Phone: 478-919-6711
  • Fax:
Mailing address:
  • Phone: 830-273-5601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JAZZMIN S MADDOX
Title or Position: CEO, FOUNDER
Credential: LPC
Phone: 478-919-6711