MEDICARE: CRYSTAL SEALS-JENKINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	1025387	VA

General Provider Information

NPI Number	:	1124415633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL SEALS-JENKINS

Provider Business Mailing Address
First Line	:	3323 WOODROW AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2720
Country	:	US
Telephone Number	:	804-338-8216
Fax Number	:

Provider Business Practice Location Address
First Line	:	3323 WOODROW AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2720
Country	:	US
Telephone Number	:	804-338-8216
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/22/2015

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