Provider Demographics
NPI:1922700152
Name:JONES, SHADAE PETER-GAY
Entity Type:Individual
Prefix:MISS
First Name:SHADAE
Middle Name:PETER-GAY
Last Name:JONES
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 1:6231 BURBAGE ACRES DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3055
Mailing Address - Country:US
Mailing Address - Phone:757-917-0132
Mailing Address - Fax:
Practice Address - Street 1:6231 BURBAGE ACRES DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3055
Practice Address - Country:US
Practice Address - Phone:757-917-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230036305183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician