Provider Demographics
NPI:1518471622
Name:IBARRA, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:IBARRA
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 1:8210 LANKFORD HWY
Mailing Address - Street 2:
Mailing Address - City:OAK HALL
Mailing Address - State:VA
Mailing Address - Zip Code:23416-2114
Mailing Address - Country:US
Mailing Address - Phone:757-824-3360
Mailing Address - Fax:
Practice Address - Street 1:8210 LANKFORD HWY
Practice Address - Street 2:
Practice Address - City:OAK HALL
Practice Address - State:VA
Practice Address - Zip Code:23416-2114
Practice Address - Country:US
Practice Address - Phone:757-824-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS0600700103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000877Medicaid