Healthcare Provider Details

I. General information

NPI: 1457817231
Provider Name (Legal Business Name): JAQURIS DASHUN BREWER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2019
Last Update Date: 02/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 W 39TH ST
NORFOLK VA
23508-2788
US

IV. Provider business mailing address

218 TRAVIS DR
LAWRENCEVILLE VA
23868-4025
US

V. Phone/Fax

Practice location:
  • Phone: 434-378-1126
  • Fax:
Mailing address:
  • Phone: 434-532-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: