Provider Demographics
NPI:1134720121
Name:POULSON, JAMEELAH
Entity type:Individual
Prefix:
First Name:JAMEELAH
Middle Name:
Last Name:POULSON
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 1:483 PAMELA DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-2274
Mailing Address - Country:US
Mailing Address - Phone:757-814-1839
Mailing Address - Fax:
Practice Address - Street 1:11214 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2207
Practice Address - Country:US
Practice Address - Phone:757-814-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist