Healthcare Provider Details

I. General information

NPI: 1912784257
Provider Name (Legal Business Name): JSAPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6275 E VIRGINIA BEACH BLVD STE 303
NORFOLK VA
23502-2851
US

IV. Provider business mailing address

6275 E VIRGINIA BEACH BLVD STE 303
NORFOLK VA
23502-2851
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-3141
  • Fax: 757-461-1658
Mailing address:
  • Phone: 757-461-3141
  • Fax: 757-461-1658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: AMANDA MORAN
Title or Position: MEMBER
Credential: DO
Phone: 757-461-3141