Healthcare Provider Details

I. General information

NPI: 1548495716
Provider Name (Legal Business Name): JENNIFER E WARTELLA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8254 ATLEE RD
MECHANICSVILLE VA
23116-1844
US

IV. Provider business mailing address

8254 ATLEE RD
MECHANICSVILLE VA
23116-1844
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-5201
  • Fax: 804-560-7962
Mailing address:
  • Phone: 804-764-5201
  • Fax: 804-560-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004110
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: