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General NPI Number Information
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NPI Number | 1275549859
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Entity Type | Organization
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Legal Business Name | JACKSON RIVER ENTERPRISES, INC.
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 08/12/2008
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Provider Practice Location Address
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Address Line | 825 W EDGEMONT DR
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City | COVINGTON
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State | VA
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Zip | 24426-2759
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Country | US
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Telephone | 540-962-3441
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Fax | 540-965-8530
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Provider Business Mailing Address
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Address Line | 825 W EDGEMONT DR
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City | COVINGTON
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State | VA
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Zip | 24426-2759
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Country | US
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Telephone | 540-962-3441
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Fax | 540-965-8530
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. SHARON ANN WALTHALL
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Credential |
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Telephone | 540-962-3441
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 170300000X
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Taxonomy Name | Genetic Counselor (M.S.)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 010173515
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License Number State | VA
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