Provider Demographics
NPI:1780307058
Name:HARLEY, JOVON
Entity type:Individual
Prefix:
First Name:JOVON
Middle Name:
Last Name:HARLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13873 PARK CENTER RD STE 150L
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3248
Mailing Address - Country:US
Mailing Address - Phone:703-479-5259
Mailing Address - Fax:
Practice Address - Street 1:13873 PARK CENTER RD STE 150L
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-3248
Practice Address - Country:US
Practice Address - Phone:703-479-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No174400000XOther Service ProvidersSpecialist
No251E00000XAgenciesHome Health
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE872269864Medicaid