Healthcare Provider Details

I. General information

NPI: 1174122162
Provider Name (Legal Business Name): JOTAVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 TITANIUM AVENUE 202
MIDLOTHIAN VA
23114
US

IV. Provider business mailing address

16407 OTTERDALE POINTE DR
MOSELEY VA
23120-1556
US

V. Phone/Fax

Practice location:
  • Phone: 804-379-7186
  • Fax: 804-379-7186
Mailing address:
  • Phone: 804-247-3195
  • Fax: 804-739-9370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. VERNON OLIVER
Title or Position: CEO/PRESIDENT
Credential: EJD, LCSW
Phone: 804-247-3195