Provider Demographics
NPI:1033290804
Name:DERBY, JENNIFER (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:DERBY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MANHATTAN SQ STE A
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6262
Mailing Address - Country:US
Mailing Address - Phone:757-838-6335
Mailing Address - Fax:757-838-0612
Practice Address - Street 1:9 MANHATTAN SQ STE A
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6262
Practice Address - Country:US
Practice Address - Phone:757-838-6335
Practice Address - Fax:757-838-0612
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205703207Q00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1033290804Medicaid
NC10332900804OtherNPI FOR LICENSED PROVIDER