Healthcare Provider Details

I. General information

NPI: 1548797459
Provider Name (Legal Business Name): JESSICA COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA GRAHAM

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 LAXTON RD STE 200
LYNCHBURG VA
24502-5294
US

IV. Provider business mailing address

2116 EDINBORO AVE
LYNCHBURG VA
24502-5321
US

V. Phone/Fax

Practice location:
  • Phone: 434-515-2041
  • Fax:
Mailing address:
  • Phone: 972-638-9627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number81098
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133002370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: