1255797189 NPI number — JENNIFER M-E RUNNER RESIDENT IN MFT

Table of content: JENNIFER M-E RUNNER RESIDENT IN MFT (NPI 1255797189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255797189 NPI number — JENNIFER M-E RUNNER RESIDENT IN MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNNER
Provider First Name:
JENNIFER
Provider Middle Name:
M-E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RESIDENT IN MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255797189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13895 HEDGEWOOD DR
Provider Second Line Business Mailing Address:
SUITE 229
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22193-7924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-659-9961
Provider Business Mailing Address Fax Number:
571-659-9964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13895 HEDGEWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 229
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22193-7924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-659-9961
Provider Business Practice Location Address Fax Number:
571-659-9964
Provider Enumeration Date:
01/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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