Provider Demographics
NPI:1124629589
Name:TRAYLOR, JADE J
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:J
Last Name:TRAYLOR
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 1:8100 THREE CHOPT RD RM 143
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4833
Mailing Address - Country:US
Mailing Address - Phone:804-269-4732
Mailing Address - Fax:
Practice Address - Street 1:8100 THREE CHOPT RD RM 143
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-4833
Practice Address - Country:US
Practice Address - Phone:804-269-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid