Provider Demographics
NPI:1396503298
Name:MOUNTAIN, JAMIE SUE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:SUE
Last Name:MOUNTAIN
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 1:2813 M ST APT D
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-6608
Mailing Address - Country:US
Mailing Address - Phone:973-868-7632
Mailing Address - Fax:
Practice Address - Street 1:2006 BREMO RD STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2438
Practice Address - Country:US
Practice Address - Phone:804-918-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0734010655390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program