Provider Demographics
NPI:1457806127
Name:WASHINGTON, JALEESA
Entity Type:Individual
Prefix:
First Name:JALEESA
Middle Name:
Last Name:WASHINGTON
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 1:926 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1054
Mailing Address - Country:US
Mailing Address - Phone:757-788-8490
Mailing Address - Fax:
Practice Address - Street 1:926 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1054
Practice Address - Country:US
Practice Address - Phone:757-788-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-18-53231106S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid