Healthcare Provider Details

I. General information

NPI: 1104521699
Provider Name (Legal Business Name): JI'VONE JEROME FREEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SAM PERRY BLVD
FREDERICKSBURG VA
22401-4453
US

IV. Provider business mailing address

1340 CENTRAL PARK BLVD STE 100
FREDERICKSBURG VA
22401-4940
US

V. Phone/Fax

Practice location:
  • Phone: 540-741-1125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101288799
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: