Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1154886539 |
---|---|
Provider Name | Miss Jacquelina Otilia Tatum |
First Address | Richmond, VA 23230-1655 |
Second Address | Richmond, VA 23230-1655 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2019 |
Last Update Date | 09/02/2019 |