Healthcare Provider Details

I. General information

NPI: 1245520717
Provider Name (Legal Business Name): JK2C, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WIMBLEDON SQ UNIT H
CHESAPEAKE VA
23320-4945
US

IV. Provider business mailing address

6105 KENT CT
SUFFOLK VA
23435-3107
US

V. Phone/Fax

Practice location:
  • Phone: 757-774-0033
  • Fax: 757-394-3094
Mailing address:
  • Phone: 757-774-0033
  • Fax: 757-394-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateVA

VIII. Authorized Official

Name: MRS. KERI NICOLE CHINNICI
Title or Position: PRESIDENT / CEO
Credential:
Phone: 757-774-0033