Provider Demographics
NPI:1891262309
Name:HENNESSEY, JELANI
Entity Type:Individual
Prefix:MR
First Name:JELANI
Middle Name:
Last Name:HENNESSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 AFTON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-7902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 WOODS WAY
Practice Address - Street 2:
Practice Address - City:STATE FARM
Practice Address - State:VA
Practice Address - Zip Code:23160-0002
Practice Address - Country:US
Practice Address - Phone:804-598-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50520225200000X
MD5069225200000X
VA2306604870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant