Healthcare Provider Details

I. General information

NPI: 1609584135
Provider Name (Legal Business Name): JESSICA CARPENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BRAMBLETON AVE
ROANOKE VA
24018-6515
US

IV. Provider business mailing address

6800 PARAGON PL STE 200
RICHMOND VA
23230-1652
US

V. Phone/Fax

Practice location:
  • Phone: 804-562-6604
  • Fax: 757-970-0277
Mailing address:
  • Phone: 804-562-6604
  • Fax: 757-970-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-202684
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: