Healthcare Provider Details

I. General information

NPI: 1831800580
Provider Name (Legal Business Name): JENNA HAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 PRESTON PARK WAY
SANDY HOOK VA
23153-2265
US

IV. Provider business mailing address

PO BOX 1090
GOOCHLAND VA
23063-1090
US

V. Phone/Fax

Practice location:
  • Phone: 804-449-7376
  • Fax:
Mailing address:
  • Phone: 804-449-7376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103691
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701010838
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: