Healthcare Provider Details

I. General information

NPI: 1346025772
Provider Name (Legal Business Name): JIVA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4439 FAIR STONE DR APT 202
FAIRFAX VA
22033-5118
US

IV. Provider business mailing address

4439 FAIR STONE DR APT 202
FAIRFAX VA
22033-5118
US

V. Phone/Fax

Practice location:
  • Phone: 240-801-6202
  • Fax:
Mailing address:
  • Phone: 240-801-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHANDNI BHATIA
Title or Position: OWNER
Credential: LPC
Phone: 240-801-6202