Provider Demographics
NPI:1841762853
Name:GURUPRASAD, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GURUPRASAD
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 1:9720 CAPITAL CT STE 104
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-2049
Mailing Address - Country:US
Mailing Address - Phone:571-359-6753
Mailing Address - Fax:
Practice Address - Street 1:9720 CAPITAL CT STE 104
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-2049
Practice Address - Country:US
Practice Address - Phone:571-359-6753
Practice Address - Fax:571-359-6637
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-2034251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAHCO-2034OtherDEPARTMENT OF THE TREASURY OF RICHMOND VA