Provider Demographics
NPI:1396728317
Name:TEASS, JEFFERSON KIRKLAND (DC)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:KIRKLAND
Last Name:TEASS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:300 VIRGINIA AVE
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-0646
Mailing Address - Country:US
Mailing Address - Phone:540-982-2920
Mailing Address - Fax:540-342-4835
Practice Address - Street 1:300 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179
Practice Address - Country:US
Practice Address - Phone:540-982-2920
Practice Address - Fax:540-342-4835
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000446111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
015913OtherANTHEM BCBS VIRGINIA