Healthcare Provider Details

I. General information

NPI: 1720995509
Provider Name (Legal Business Name): JEIDY MARMOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14715 BRISTOW RD
MANASSAS VA
20112-3945
US

IV. Provider business mailing address

3105 CLOVER LN
CULPEPER VA
22701-3988
US

V. Phone/Fax

Practice location:
  • Phone: 703-791-8845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204001838
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: