Provider Demographics
NPI:1144649567
Name:PREMKUMAR, BEENA JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:BEENA
Middle Name:JENNIFER
Last Name:PREMKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5719
Mailing Address - Country:US
Mailing Address - Phone:540-373-3223
Mailing Address - Fax:540-371-3753
Practice Address - Street 1:600 JACKSON ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5719
Practice Address - Country:US
Practice Address - Phone:540-373-3223
Practice Address - Fax:540-371-3753
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-31932084P0804X
VA01012644892084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08380581Medicaid