Provider Demographics
NPI:1457817231
Name:BREWER, JAQURIS DASHUN
Entity Type:Individual
Prefix:
First Name:JAQURIS
Middle Name:DASHUN
Last Name:BREWER
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 1:218 TRAVIS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868-4025
Mailing Address - Country:US
Mailing Address - Phone:434-532-3450
Mailing Address - Fax:
Practice Address - Street 1:1037 W 39TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2788
Practice Address - Country:US
Practice Address - Phone:434-378-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA83-3462452Medicaid