Provider Demographics
NPI:1902314701
Name:GARDNER, JAHLEEL
Entity Type:Individual
Prefix:
First Name:JAHLEEL
Middle Name:
Last Name:GARDNER
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 1:3633 CHASE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6804
Mailing Address - Country:US
Mailing Address - Phone:757-650-0485
Mailing Address - Fax:757-650-0485
Practice Address - Street 1:3633 CHASE CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6804
Practice Address - Country:US
Practice Address - Phone:757-650-0485
Practice Address - Fax:757-650-0485
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-17-40907106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA932220747OtherUNITEDHEALTHCARE