Healthcare Provider Details

I. General information

NPI: 1669869962
Provider Name (Legal Business Name): JESSICA KANDL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E. MARSHALL ST POB 980146
RICHMOND VA
23298-0146
US

IV. Provider business mailing address

1250 E. MARSHALL ST POB 980257
RICHMOND VA
23298-0257
US

V. Phone/Fax

Practice location:
  • Phone: 804-628-4368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0116029063
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101261359
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: