Healthcare Provider Details

I. General information

NPI: 1811391790
Provider Name (Legal Business Name): JANE NICOLL BUMGARNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 JACKSON ST
FREDERICKSBURG VA
22401-5719
US

IV. Provider business mailing address

600 JACKSON ST
FREDERICKSBURG VA
22401-5719
US

V. Phone/Fax

Practice location:
  • Phone: 540-373-3223
  • Fax: 540-371-3753
Mailing address:
  • Phone: 540-373-3223
  • Fax: 540-371-3753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904010276
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: