=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467309716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA WEAVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2026
-----------------------------------------------------
Last Update Date | 03/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 THUNDER RD
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-549-2887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 HORNSWOOD CT
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-7760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 0001299269
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------