Healthcare Provider Details

I. General information

NPI: 1083540876
Provider Name (Legal Business Name): JESSICA LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 N AUGUSTA ST
STAUNTON VA
24401-2526
US

IV. Provider business mailing address

2509 N AUGUSTA ST
STAUNTON VA
24401-2526
US

V. Phone/Fax

Practice location:
  • Phone: 434-465-0984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701015969
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: