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General NPI Number Information
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NPI Number | 1164069886
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Entity Type | Individual
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Provider Name | ASHANTIANA WILSHENA, JEMILA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 12/01/2019
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Last Update Date | 12/01/2019
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Provider Practice Location Address
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Address Line | 648 INDEPENDENCE PKWY STE 300
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City | CHESAPEAKE
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State | VA
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Zip | 23320-5208
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Country | US
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Telephone | 757-776-0790
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Fax |
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Provider Business Mailing Address
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Address Line | 1408 QUIET CT
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City | PORTSMOUTH
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State | VA
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Zip | 23701-3618
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Country | US
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Telephone | 757-289-9049
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | A60633323
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License Number State | VA
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