Provider Demographics
NPI:1669681094
Name:HUMBERSON, JENNIFER B (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:B
Last Name:HUMBERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5875 BREMO RD STE 500
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1928
Practice Address - Country:US
Practice Address - Phone:804-297-3055
Practice Address - Fax:804-297-3056
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250453207SG0201X
NC2009-01353207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1589KOtherBCBSNC
VA1669681094Medicaid
NC5915249Medicaid
VAVV4213AMedicare PIN
VA1669681094Medicaid