Healthcare Provider Details

I. General information

NPI: 1598735417
Provider Name (Legal Business Name): JONATHAN GENTRY CRISP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 08/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 BAGLEY CIR
MARION VA
24354-3126
US

IV. Provider business mailing address

340 BAGLEY CIR
MARION VA
24354-3126
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-1226
  • Fax: 276-783-1425
Mailing address:
  • Phone: 276-783-1226
  • Fax: 276-783-1425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9700221
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101239503
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: