Provider Demographics
NPI:1700285723
Name:BRULTZ, JANA (LPC)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:BRULTZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 MCLAWS CIRCLE, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185
Mailing Address - Country:US
Mailing Address - Phone:757-345-6428
Mailing Address - Fax:757-345-6808
Practice Address - Street 1:215 MCLAWS CIRCLE, SUITE 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-345-6428
Practice Address - Fax:757-345-6808
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003392101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional