Healthcare Provider Details

I. General information

NPI: 1255115523
Provider Name (Legal Business Name): MR. JERRY LEE MIZE II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

2709 POPLAR HAVEN CT
RICHMOND VA
23223-2172
US

IV. Provider business mailing address

2709 POPLAR HAVEN CT
RICHMOND VA
23223-2172
US

V. Phone/Fax

Practice location:
  • Phone: 804-691-6957
  • Fax:
Mailing address:
  • Phone: 804-691-6957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: