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General NPI Number Information
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NPI Number | 1982231403
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Entity Type | Individual
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Provider Name | JAXON VALLELY
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Gender | Male
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Dates
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Enumeration Date | 03/25/2020
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Last Update Date | 03/25/2020
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Provider Practice Location Address
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Address Line | 358 MOWBRAY ARCH, SUITE #203/205
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City | NORFOLK
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State | VA
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Zip | 23507
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Country | US
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Telephone | 757-668-7249
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Fax |
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Provider Business Mailing Address
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Address Line | 417 CLOVER LN APT A
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City | RALEIGH
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State | NC
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Zip | 27604-2055
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Country | US
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Telephone | 267-247-2295
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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