Healthcare Provider Details

I. General information

NPI: 1003370321
Provider Name (Legal Business Name): JEREMY WAYNE STOUT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 BROAD ROCK BLVD
RICHMOND VA
23249-1899
US

IV. Provider business mailing address

269 LOOKOUT HILL RD
MILFORD CT
06461-1899
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5000
  • Fax:
Mailing address:
  • Phone: 808-375-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY10800
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: