Provider Demographics
NPI:1841242526
Name:HALL, JAMIE DERESA (F NP, GNP)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:DERESA
Last Name:HALL
Suffix:
Gender:F
Credentials:F NP, GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BAGLEY CIRCLE
Mailing Address - Street 2:SOUTHWESTERN VIRGINIA MENTAL HEALTH INSTITUTE
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354
Mailing Address - Country:US
Mailing Address - Phone:276-783-1200
Mailing Address - Fax:
Practice Address - Street 1:340 BAGLEY CIRCLE
Practice Address - Street 2:SOUTHWESTERN VIRGINIA MENTAL HEALTH INSTITUTE
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-9998
Practice Address - Country:US
Practice Address - Phone:276-783-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001073929363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010261546Medicaid