Provider Demographics
NPI:1972202695
Name:DENNIS, JERRON A SR
Entity Type:Individual
Prefix:
First Name:JERRON
Middle Name:A
Last Name:DENNIS
Suffix:SR
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 1:6001 LAKESIDE AVE STE 36
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5749
Mailing Address - Country:US
Mailing Address - Phone:804-814-7375
Mailing Address - Fax:
Practice Address - Street 1:6001 LAKESIDE AVE STE 36
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-5749
Practice Address - Country:US
Practice Address - Phone:804-814-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)