Healthcare Provider Details

I. General information

NPI: 1265069504
Provider Name (Legal Business Name): JACQUETTA DELSHAWN GARRIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUETTA GARRIS PMHNP-BC

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 FIRST COLONIAL RD STE A
VIRGINIA BEACH VA
23454-3078
US

IV. Provider business mailing address

2827 VICTORIA AVE
NORFOLK VA
23504-4523
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-1850
  • Fax: 757-222-9360
Mailing address:
  • Phone: 757-718-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024180091
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number0001213031
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: