Healthcare Provider Details

I. General information

NPI: 1942618434
Provider Name (Legal Business Name): JENNIFER RIQUELME LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER BARANY LPC

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 ROBIN HOOD RD STE C1
NORFOLK VA
23513-2423
US

IV. Provider business mailing address

5505 ROBIN HOOD RD STE C1
NORFOLK VA
23513-2423
US

V. Phone/Fax

Practice location:
  • Phone: 757-823-1630
  • Fax:
Mailing address:
  • Phone: 757-823-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701005272
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005272
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: