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General NPI Number Information
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NPI Number | 1710404835
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Entity Type | Individual
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Provider Name | JARED AMBROSE
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Gender | Male
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Dates
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Enumeration Date | 08/29/2017
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Last Update Date | 08/29/2017
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Provider Practice Location Address
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Address Line | 3623 SAUNDERS AVE
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City | RICHMOND
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State | VA
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Zip | 23227-4354
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Country | US
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Telephone | 804-601-6751
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Fax |
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Provider Business Mailing Address
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Address Line | 1314 MISTYVALE ST
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City | HERNDON
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State | VA
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Zip | 20170-3629
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Country | US
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Telephone | 703-407-5011
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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