Healthcare Provider Details

I. General information

NPI: 1174942700
Provider Name (Legal Business Name): JESSICA HUPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11958 W BROAD ST
HENRICO VA
23233
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-360-4669
  • Fax: 804-364-6557
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101264679
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: