Provider Demographics
NPI:1982977633
Name:BRICKWEDDE, JEA CATHERINE
Entity Type:Individual
Prefix:
First Name:JEA
Middle Name:CATHERINE
Last Name:BRICKWEDDE
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 1:716 RIO RD W
Mailing Address - Street 2:FA
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901
Mailing Address - Country:US
Mailing Address - Phone:434-960-5153
Mailing Address - Fax:434-964-0865
Practice Address - Street 1:716 RIO RD W
Practice Address - Street 2:FA
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901
Practice Address - Country:US
Practice Address - Phone:434-960-5153
Practice Address - Fax:434-964-0865
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2378804174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist