Provider Demographics
NPI:1255921110
Name:KEARNEY, JEWELL (NA)
Entity type:Individual
Prefix:
First Name:JEWELL
Middle Name:
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2013
Mailing Address - Country:US
Mailing Address - Phone:804-520-2220
Mailing Address - Fax:
Practice Address - Street 1:3701 E RIVER RD
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23803-2013
Practice Address - Country:US
Practice Address - Phone:804-520-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12010641901744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty