Provider Demographics
NPI:1831492008
Name:SELF, JOLENE K
Entity Type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:K
Last Name:SELF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 BRYANTS TOWN RD
Mailing Address - Street 2:
Mailing Address - City:FARNHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22460-3025
Mailing Address - Country:US
Mailing Address - Phone:804-761-4579
Mailing Address - Fax:
Practice Address - Street 1:749 BRYANTS TOWN RD
Practice Address - Street 2:
Practice Address - City:FARNHAM
Practice Address - State:VA
Practice Address - Zip Code:22460-3025
Practice Address - Country:US
Practice Address - Phone:804-761-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator