Healthcare Provider Details

I. General information

NPI: 1578532461
Provider Name (Legal Business Name): BETTY JAYNE EASTMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 WYTHE CREEK RD STE C
POQUOSON VA
23662-1926
US

IV. Provider business mailing address

370 WYTHE CREEK RD STE C SUITE C
POQUOSON VA
23662-1926
US

V. Phone/Fax

Practice location:
  • Phone: 757-868-0072
  • Fax: 757-868-0087
Mailing address:
  • Phone: 757-868-0072
  • Fax: 757-868-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number9040004680
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004680
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: