Healthcare Provider Details

I. General information

NPI: 1265819957
Provider Name (Legal Business Name): JESSE LEMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 DOGTOWN RD
GOOCHLAND VA
23063-2424
US

IV. Provider business mailing address

30 CHASE GAYTON CIR APT 833
RICHMOND VA
23238-6534
US

V. Phone/Fax

Practice location:
  • Phone: 804-556-4418
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604083
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: