=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649118811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC LONGEVITY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2026
-----------------------------------------------------
Last Update Date | 03/23/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14017 TELEGRAPH RD
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-4611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-987-7444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6111 OAKLAWN LN
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22193-3969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-987-7444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NUTRITIONIST
-----------------------------------------------------
Name | JAMIE BULLARD
-----------------------------------------------------
Credential | CPT, BCS, FNS
-----------------------------------------------------
Telephone | 703-987-7444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------