Provider Demographics
NPI:1477387751
Name:LARYEA, JEMIMA
Entity type:Individual
Prefix:
First Name:JEMIMA
Middle Name:
Last Name:LARYEA
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 1:14109 COVE LANDING DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-2261
Mailing Address - Country:US
Mailing Address - Phone:774-670-2790
Mailing Address - Fax:
Practice Address - Street 1:188 OVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-2261
Practice Address - Country:US
Practice Address - Phone:774-670-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst