Provider Demographics
NPI:1902339401
Name:NEELEY, JERRID
Entity Type:Individual
Prefix:
First Name:JERRID
Middle Name:
Last Name:NEELEY
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 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:7547 MEDICAL DR STE 1200
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4351
Practice Address - Country:US
Practice Address - Phone:804-693-2670
Practice Address - Fax:804-693-3704
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206146207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program