Healthcare Provider Details

I. General information

NPI: 1356791107
Provider Name (Legal Business Name): JENNA BEDNAREK QASP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4224 HOLLAND RD 106
VIRGINIA BEACH VA
23453-2345
US

IV. Provider business mailing address

1217 NEW LAND DRIVE
VIRGINIA BEACH VA
23453
US

V. Phone/Fax

Practice location:
  • Phone: 757-416-5290
  • Fax:
Mailing address:
  • Phone: 812-374-2168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: