Healthcare Provider Details

I. General information

NPI: 1386471258
Provider Name (Legal Business Name): CIERRA JENNESTREET DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 MCLAWS CIR
WILLIAMSBURG VA
23185-5649
US

IV. Provider business mailing address

219 MCLAWS CIR
WILLIAMSBURG VA
23185-5649
US

V. Phone/Fax

Practice location:
  • Phone: 757-259-1121
  • Fax:
Mailing address:
  • Phone: 757-259-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH15180
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104558040
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: