Provider Demographics
NPI:1235964131
Name:ANDERSON, JENNIFER LEE (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4360 SHORE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-2994
Mailing Address - Country:US
Mailing Address - Phone:757-251-0879
Mailing Address - Fax:984-220-9437
Practice Address - Street 1:4360 SHORE DR STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-2994
Practice Address - Country:US
Practice Address - Phone:757-251-0879
Practice Address - Fax:984-220-9437
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704017275390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program