Provider Demographics
NPI:1831835800
Name:RIVENBARK, JOLIE (RN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JOLIE
Middle Name:
Last Name:RIVENBARK
Suffix:
Gender:F
Credentials:RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14130 NOBLEWOOD PLZ STE 306
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1467
Mailing Address - Country:US
Mailing Address - Phone:703-485-0470
Mailing Address - Fax:
Practice Address - Street 1:14130 NOBLEWOOD PLZ STE 306
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1467
Practice Address - Country:US
Practice Address - Phone:703-485-0470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1677126163W00000X
VA0024189696363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse