Healthcare Provider Details

I. General information

NPI: 1194030874
Provider Name (Legal Business Name): JEREMIAH FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9513 HULL STREET RD STE A
NORTH CHESTERFIELD VA
23236-1495
US

IV. Provider business mailing address

PO BOX 4504
MIDLOTHIAN VA
23112-0010
US

V. Phone/Fax

Practice location:
  • Phone: 804-608-9389
  • Fax: 804-763-3453
Mailing address:
  • Phone: 804-399-1993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004489
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ANN KELL
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 804-608-9389