=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962733543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANNE UPTON D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2010
-----------------------------------------------------
Last Update Date | 01/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1248 W DANVILLE ST
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-447-3049
-----------------------------------------------------
Fax | 434-447-3049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1248 W DANVILLE ST
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-447-3049
-----------------------------------------------------
Fax | 434-447-3049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104556743
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------