Healthcare Provider Details

I. General information

NPI: 1639463151
Provider Name (Legal Business Name): PRINCESS JEFFERS CNC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRINCESS JEFFERS CMT, CIMI

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8014 MIDLOTHIAN TPKE SUITE 200 A
RICHMOND VA
23235-5291
US

IV. Provider business mailing address

PO BOX 35229
RICHMOND VA
23235-0229
US

V. Phone/Fax

Practice location:
  • Phone: 804-592-4751
  • Fax: 804-592-4752
Mailing address:
  • Phone: 804-592-4751
  • Fax: 804-592-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number0019005982
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: