Provider Demographics
NPI:1780180109
Name:WHITE, JENNIFER LEE (MS, QMHP-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS, QMHP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 BURNETTS WAY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8048
Mailing Address - Country:US
Mailing Address - Phone:757-641-6357
Mailing Address - Fax:
Practice Address - Street 1:304 BURNETTS WAY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8048
Practice Address - Country:US
Practice Address - Phone:757-641-6357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No172A00000XOther Service ProvidersDriver