Provider Demographics
NPI:1205338308
Name:HART, JEFFREY (MA)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:HART
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 BLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-3114
Mailing Address - Country:US
Mailing Address - Phone:804-466-1203
Mailing Address - Fax:
Practice Address - Street 1:1 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3568
Practice Address - Country:US
Practice Address - Phone:757-727-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000375103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool