Healthcare Provider Details

I. General information

NPI: 1538097530
Provider Name (Legal Business Name): JACE DEPRIEST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 GREEN HOLLOW LN
SANDSTON VA
23150-2153
US

IV. Provider business mailing address

312 GREEN HOLLOW LN
SANDSTON VA
23150-2153
US

V. Phone/Fax

Practice location:
  • Phone: 804-759-5005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: