Provider Demographics
NPI:1437754660
Name:NEAL, JACARRI
Entity Type:Individual
Prefix:
First Name:JACARRI
Middle Name:
Last Name:NEAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 COLGIN DR APT 303
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-0004
Mailing Address - Country:US
Mailing Address - Phone:757-502-9122
Mailing Address - Fax:
Practice Address - Street 1:287 INDEPENDENCE BLVD, PEMBROKE BUILDING 2, SUITE 322
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455
Practice Address - Country:US
Practice Address - Phone:757-502-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6047852541Medicaid