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General NPI Number Information
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NPI Number | 1629518121
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Entity Type | Organization
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Legal Business Name | JKT TRAUMA CONSULTATION COUNSELING AND TRAINING SERVICES
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Dates
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Enumeration Date | 03/02/2017
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Last Update Date | 07/05/2019
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Provider Practice Location Address
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Address Line | 1901 HUGUENOT RD STE 303
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-4311
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Country | US
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Telephone | 804-794-6247
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Fax | 804-794-6247
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Provider Business Mailing Address
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Address Line | 1901 HUGUENOT RD STE 303
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-4311
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Country | US
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Telephone | 804-794-6247
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Fax | 804-794-6247
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Authorized Official
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Title or Position | OWNER
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Name | ELIZABETH DELORES DUNGEE- ANDERSON
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Credential | PHD
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Telephone | 804-840-1149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0904000543
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License Number State | VA
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