Healthcare Provider Details

I. General information

NPI: 1750293833
Provider Name (Legal Business Name): JACLYN MICHELLE HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12320 W BROAD ST STE 205
RICHMOND VA
23233-7603
US

IV. Provider business mailing address

12320 W BROAD ST STE 205
RICHMOND VA
23233-7603
US

V. Phone/Fax

Practice location:
  • Phone: 804-245-8917
  • Fax:
Mailing address:
  • Phone: 804-245-8917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0136000701
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: