Provider Demographics
NPI:1124259320
Name:CLEVELAND, JENNIFER LEE
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEE
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 LAUREL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8081
Mailing Address - Country:US
Mailing Address - Phone:540-293-4999
Mailing Address - Fax:540-977-0297
Practice Address - Street 1:1663 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:TROUTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24175-6636
Practice Address - Country:US
Practice Address - Phone:540-977-4224
Practice Address - Fax:540-977-0297
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist